[House Hearing, 113 Congress] [From the U.S. Government Publishing Office] EXAMINING SAMHSA'S ROLE IN DELIVERING SERVICES TO THE SEVERELY MENTALLY ILL ======================================================================= HEARING BEFORE THE SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS OF THE COMMITTEE ON ENERGY AND COMMERCE HOUSE OF REPRESENTATIVES ONE HUNDRED THIRTEENTH CONGRESS FIRST SESSION __________ MAY 22, 2013 __________ Serial No. 113-47 Printed for the use of the Committee on Energy and Commerce energycommerce.house.gov ---------- U.S. GOVERNMENT PRINTING OFFICE 85-437 PDF WASHINGTON : 2013 ----------------------------------------------------------------------- For sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpo.gov Phone: toll free (800) 512-1800; DC area (202) 512-1800 Fax: (202) 512-214 Mail: Stop IDCC, Washington, DC 20402-0001 COMMITTEE ON ENERGY AND COMMERCE FRED UPTON, Michigan Chairman RALPH M. HALL, Texas HENRY A. WAXMAN, California JOE BARTON, Texas Ranking Member Chairman Emeritus JOHN D. DINGELL, Michigan ED WHITFIELD, Kentucky Chairman Emeritus JOHN SHIMKUS, Illinois EDWARD J. MARKEY, Massachusetts JOSEPH R. PITTS, Pennsylvania FRANK PALLONE, Jr., New Jersey GREG WALDEN, Oregon BOBBY L. RUSH, Illinois LEE TERRY, Nebraska ANNA G. ESHOO, California MIKE ROGERS, Michigan ELIOT L. ENGEL, New York TIM MURPHY, Pennsylvania GENE GREEN, Texas MICHAEL C. BURGESS, Texas DIANA DeGETTE, Colorado MARSHA BLACKBURN, Tennessee LOIS CAPPS, California Vice Chairman MICHAEL F. DOYLE, Pennsylvania PHIL GINGREY, Georgia JANICE D. SCHAKOWSKY, Illinois STEVE SCALISE, Louisiana JIM MATHESON, Utah ROBERT E. LATTA, Ohio G.K. BUTTERFIELD, North Carolina CATHY McMORRIS RODGERS, Washington JOHN BARROW, Georgia GREGG HARPER, Mississippi DORIS O. MATSUI, California LEONARD LANCE, New Jersey DONNA M. CHRISTENSEN, Virgin BILL CASSIDY, Louisiana Islands BRETT GUTHRIE, Kentucky KATHY CASTOR, Florida PETE OLSON, Texas JOHN P. SARBANES, Maryland DAVID B. McKINLEY, West Virginia JERRY McNERNEY, California CORY GARDNER, Colorado BRUCE L. BRALEY, Iowa MIKE POMPEO, Kansas PETER WELCH, Vermont ADAM KINZINGER, Illinois BEN RAY LUJAN, New Mexico H. MORGAN GRIFFITH, Virginia PAUL TONKO, New York GUS M. BILIRAKIS, Florida BILL JOHNSON, Missouri BILLY LONG, Missouri RENEE L. ELLMERS, North Carolina Subcommittee on Oversight and Investigations TIM MURPHY, Pennsylvania Chairman MICHAEL C. BURGESS, Texas DIANA DeGETTE, Colorado Vice Chairman Ranking Member MARSHA BLACKBURN, Tennessee BRUCE L. BRALEY, Iowa PHIL GINGREY, Georgia BEN RAY LUJAN, New Mexico STEVE SCALISE, Louisiana EDWARD J. MARKEY, Massachusetts GREGG HARPER, Mississippi JANICE D. SCHAKOWSKY, Illinois PETE OLSON, Texas G.K. BUTTERFIELD, North Carolina CORY GARDNER, Colorado KATHY CASTOR, Florida H. MORGAN GRIFFITH, Virginia PETER WELCH, Vermont BILL JOHNSON, Ohio PAUL TONKO, New York BILLY LONG, Missouri GENE GREEN, Texas RENEE L. ELLMERS, North Carolina JOHN D. DINGELL, Michigan JOE BARTON, Texas HENRY A. WAXMAN, California (ex FRED UPTON, Michigan (ex officio) officio) C O N T E N T S ---------- Page Hon. Tim Murphy, a Representative in Congress from the Commonwealth of Pennsylvania, opening statement................ 1 Prepared statement........................................... 4 Hon. Diana DeGette, a Representative in Congress from the State of Colorado, opening statement................................. 6 Hon. Fred Upton, a Representative in Congress from the State of Michigan, opening statement.................................... 7 Prepared statement........................................... 8 Hon. G.K. Butterfield, a Representative in Congress from the State of North Carolina, opening statement..................... 10 Hon. Henry A. Waxman, a Representative in Congress from the State of California, prepared statement.............................. 11 Witnesses Pamela S. Hyde, Administrator, Substance Abuse and Mental Health Services Administration........................................ 13 Prepared statement........................................... 15 Answers to submitted questions............................... 165 Joseph Bruce, Father of a Son with Severe Mental Illness......... 57 Prepared statement........................................... 61 Answers to submitted questions............................... 202 E. Fuller Torrey, Founder, Treatment Advocacy Center............. 67 Prepared statement........................................... 70 Answers to submitted questions............................... 206 Sally Satel, Resident Scholar, American Enterprise Institute..... 82 Prepared statement........................................... 84 Answers to submitted questions............................... 211 Joseph Parks, III, Chief Clinical Officer, Missouri Department of Mental Health.................................................. 91 Prepared statement........................................... 94 Answers to submitted questions............................... 213 Submitted Material Document binder.................................................. 115 EXAMINING SAMHSA'S ROLE IN DELIVERING SERVICES TO THE SEVERELY MENTALLY ILL ---------- WEDNESDAY, MAY 22, 2013 House of Representatives, Subcommittee on Oversight and Investigations, Committee on Energy and Commerce, Washington, DC. The subcommittee met, pursuant to call, at 10:05 a.m., in room 2123 of the Rayburn House Office Building, Hon. Tim Murphy (chairman of the subcommittee) presiding. Members present: Representatives Murphy, Burgess, Blackburn, Gingrey, Scalise, Harper, Olson, Gardner, Griffith, Johnson, Long, Ellmers, Upton (ex officio), DeGette, Braley, Butterfield, Castor, Tonko, Green, and Waxman (ex officio). Also present: Representative Cassidy. Staff present: Karen Christian, Chief Counsel, Oversight; Brad Grantz, Policy Coordinator, O&I; Brittany Havens, Legislative Clerk; Robert Horne, Professional Staff Member, Health; Alan Slobodin, Deputy Chief Counsel, Oversight; Sam Spector, Counsel, Oversight; Jean Woodrow, Director, Information Technology; Stacia Cardille, Democratic Deputy Chief Counsel; Anne Morris Reid, Democratic Professional Staff; Brian Cohen, Democratic Staff Director for Oversight and Investigations Subcommittee and Senior Policy Advisor; Stephen Salsbury, Democratic Special Assistant; and Elizabeth Letter, Democratic Assistant Press Secretary. OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA Mr. Murphy. Good morning, everyone. I now convene this morning's hearing entitled ``Examining SAMHSA's Role in Delivering Services to the Severely Mentally Ill.'' Since I became the Chairman of the Subcommittee on Oversight and Investigations, shortly after the December 14, 2012, elementary school shootings in Newtown of last year, we began looking into the federal programs and the resources devoted to mental health and mental illness. We did so to ensure federal dollars devoted to mental health are reaching those individuals with serious mental illness and helping them obtain the most effective care. One lesson we must immediately draw from the Newtown tragedy is that we need to make it our priority to get those with serious mental illness who are not presently being treated into sound, evidence-based treatments. In 2009, the Substance Abuse and Mental Health Services Administration, otherwise known as SAMHSA, estimates that about 11 million U.S. adults had serious mental illness, and 40 percent of these individuals did not receive treatment. While the vast majority of individuals with a mental health condition are nonviolent, director of the National Institute for Mental Health, Dr. Thomas Insel, told this subcommittee at our March 5 public forum that effective treatments, which include medication adherence and evidence-based psychosocial psychotherapy, can reduce the risk of violent behavior 15-fold in persons with serious mental illness. Getting these individuals into treatment is a crucial first task, and SAMHSA, as the federal agency whose mission includes reducing the impact of mental illness on America's communities, should be playing a central role in this effort. But based on our work to date, SAMHSA has not made the treatment of the seriously mentally ill a priority. In fact, I am afraid serious mental illness such as schizophrenia and bipolar disorder may not be a concern at all. Consider the 2011-2014 SAMHSA strategic plan entitled ``Leading Change.'' SAMHSA continues to think in broad terms such as ``behavioral'' and ``emotional'' health, promoting such concepts as ``wellness'' or ``recovery.'' Not once in this entire 117-page document will you find the words schizophrenia or bipolar disorder. Nowhere in the written testimony that was provided to this committee yesterday by the SAMHSA administrator do those words appear. And nowhere on SAMHSA's Web site or in their publications can you learn about the increased risk of violent behavior by persons with untreated mental illness. It is as if SAMHSA doesn't believe serious mental illness exists. If we have learned one thing from the horrible acts committed by Seung-Hui Cho at Virginia Tech in 2007; Jared Loughner in Tucson; James Holmes at the Aurora, Colorado, theater in July 2012; or Adam Lanza, it is this: that individuals with untreated severe mental illness are a significant target for self-directed violence, including suicide or violence against others. In at least 38 of the last 62 mass killings, the perpetrator displayed signs of possible mental health problems. In so many of these instances, parents desperately tried to get their mentally ill loved one to help before the act. Sadly, they failed, oftentimes because the current system of care for those with serious mental illness is broken. Examining what SAMHSA is doing to grapple with this heartbreaking truth is the main reason we are gathered here this morning. The Center for Mental Health Services, housed at SAMHSA, has a budget of approximately $1 billion per year. It awards most of these funds through a combination of competitive and formula grants. I am concerned because the Committee has seen substantial evidence that too many of these grants are directed to advancing services rooted in unproven social theory and feel-good fads rather than science. If SAMHSA were to use an evidence-based approach to identifying how to prioritize its resources--like other federal agencies do--would their record, not to mention their strategic initiatives going forward, look the same as they do now? For example, in 2012, an annual conference that has been funded by SAMHSA for many years at which the SAMHSA administrator herself regularly delivers a keynote, a conference known as Alternatives, an hour-and-a-half workshop was held, described as follows: ``Unleash the Beast is a mind/ body fitness program that looks to the animals of the jungle for wisdom and skills that can benefit our lives in a myriad of ways. Through animal-inspired movements, behaviors, and expressions, participants are encouraged to shed layers of formal conditioning in order to return to their primal nature.'' While mental and physical health is important, I question the value of this exercise in advancing the treatment for mental illness in humans let alone seriously mentally ill, and I question if there is any scientific merit at all. I would also ask why SAMHSA provides grant funding year after year in the millions of dollars in aggregate to organizations that are outwardly hostile to the sciences of psychiatry and psychology. These groups openly deny that mental illness exists, claiming there is nothing out of the ordinary when an individual hears voices or experiences extreme mental states, and that these should be celebrated as nature's gift to mankind, contributing to artistic creativity and human diversity. Leaders of these organizations--including at least one of which SAMHSA has elevated to the status of a ``National Technical Assistance Center'' and received at least $300,000 in taxpayer dollars the past year--have actively encouraged supporters to ``occupy'' the 2012 annual convention of the American Psychiatric Association, decrying the professional association's role in developing the Diagnostic and Statistical Manual of Mental Disorders, otherwise known as the DSM. ``Psychiatric labeling,'' as they say, is ``a pseudoscientific practice of limited value in helping people recover.'' When SAMHSA-funded organizations are not busy encouraging those with mental illness to go off their prescribed medications--and, yes, they do that--or destroying trust between individuals with serious mental illness, their family caregivers, and their physicians, these taxpayer-backed groups are actively lobbying against effective evidence-based treatment like Assisted Outpatient Treatment--otherwise known as AOT--laws, a less-restrictive alternative to involuntary commitment is what AOT is. Numerous academic studies have shown AOT to be incredibly effective in reducing re-hospitalizations and re-arrests among, until-then, untreated individuals with serious mental illness. As an agency of the U.S. Public Health Service, we expect SAMHSA's work to be firmly rooted in evidence-based practices in deed and not just by word, enduring high-level scientific peer review at the hands of licensed mental health professionals. Perhaps some of it is and I know some of it is, but much of it appears to fall far short of such standards. To get answers to our questions, this morning, we will hear from Pamela Hyde, the Administrator of SAMHSA since 2009, on our first panel. On our second panel, we will hear from E. Fuller Torrey, a psychiatrist and long-time observer of SAMHSA; Dr. Sally Satel, a member of the National Advisory Council to SAMHSA's Center for Mental Health Services for 4 years; and Joe Bruce, a family man from Caratunk, Maine, whose life was irrevocably changed by one SAMHSA program in particular. Joe's wife, Amy, was murdered by their son, Will, only months after being released from a psychiatric hospital where he had been treated for schizophrenia. Reflecting on this horrific act several years ago, Will noted that, un-medicated at the time, he believed he was a clandestine operative under orders to kill his mother, an Al Qaeda operative. Joe believes the efforts of a SAMHSA-funded organization obtained his son's premature release from the hospital without putting in place a mechanism for ensuring that Will would remain on his medication. Joe, we extend our condolences to you and your family, and thank you for sharing your moving story with us today. We will also hear from Dr. Joseph Parks, III, Chief Clinical Officer of the Missouri Department of Mental Health, who has substantial experience working with SAMHSA grant funded-projects. And I want to thank all of our witnesses for being here today. [The prepared statement of Mr. Murphy follows:] Prepared statement of Hon. Tim Murphy Since I became the Chairman of the Subcommittee on Oversight and Investigations, shortly after the December 14, 2012, elementary school shootings in Newtown, we began looking into the federal programs and resources devoted to mental health and mental illness. We did so to ensure federal dollars devoted to mental health are reaching those individuals with serious mental illness and helping them obtain the most effective care. One lesson we must immediately draw from the Newtown tragedy is that we need to make it our priority to get those with serious mental illnesses, who are not presently being treated, into sound, evidence-based treatments. In 2009, the Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that about 11 million U.S. adults had serious mental illness, and 40 percent of these individuals did not receive treatment. While the vast majority of individuals with a mental health condition are nonviolent, Director of the National Institute for Mental Health, Dr. Thomas Insel, told this subcommittee at our March 5 public forum that effective treatments, which include medication adherence and evidence-based psychosocial therapy, can reduce the risk of violent behavior fifteen-fold in persons with serious mental illness. Getting these individuals into treatment is a crucial first task and SAMHSA, as the federal agency whose mission includes reducing the impact of mental illness on America's communities, should be playing a central role in this effort. But based on our work to date, SAMHSA has not made the treatment of the seriously mentally ill a priority. In fact, I'm afraid serious mental illness such as schizophrenia and bipolar disorder may not be a concern at all to SAMHSA. Consider the 2011-2014 SAMHSA strategic plan entitled ``Leading Change.'' SAMHSA continues to think in broad terms of ``behavioral'' and ``emotional'' health, promoting such concepts as ``wellness'' and ``recovery.'' Not once in this entire 117 page document will you find the words schizophrenia or bipolar disorder. Nowhere in the testimony that was provided to this committee yesterday by the SAMHSA administrator do those words appear. And nowhere on SAMHSA's web site or in their publications can you learn about the increased risk of violent behavior by persons with untreated serious mental illness. It's as if SAMHSA doesn't believe serious mental illness exists. If we've learned one thing from the horrible acts committed by Seung-Hui Cho at Virginia Tech in 2007, Jared Loughner in Tuscon, James Holmes at the Aurora, Colorado, theater in July 2012, or Adam Lanza, it is that the individuals with untreated severe mental illness are a significant target for self- directed violence, including suicide, or violence against others. In at least 38 of the last 62 mass killings, the perpetrator displayed signs of possible mental health problems. In so many of these instances, parents desperately tried to get their mentally ill loved one help before the act. Sadly, they failed because the current system of care for those with serious mental illness is broken. Examining what SAMHSA is doing to grapple with this heartbreaking truth is the main reason we are gathered here this morning. The Center for Mental Health Services, housed at SAMHSA, has a budget of approximately $1 billion per year. It awards most of these funds through a combination of competitive and formula grants. I'm concerned, because the committee has seen substantial evidence that too many of these grants are directed to advancing services rooted in unproven social theory and feel-good fads, rather than science. If SAMHSA were to use an evidence-based approach to identifying how to prioritize its resources--like other federal agencies do--would their record, not to mention their strategic initiatives going forward, look the same as they do now? For example, in 2012, an annual conference that has been funded by SAMHSA for many years--and at which the SAMHSA administrator regularly delivers a keynote--Alternatives, an hour and a half workshop was held, described as follows: Unleash the Beast is a mind/body fitness program that looks to the animals of the jungle for wisdom and skills that can benefit our lives in a myriad of ways. Through animal-inspired movements, behaviors, and expressions, participants are encouraged to shed layers of formal conditioning in order to return to their primal nature. While mental and physical health is important, I question the value of this exercise in advancing the treatment for mental illness in humans. And, I question if there is any scientific merit. I would also ask why SAMHSA provides grant funding, year after year--in the millions of dollars in aggregate--to organizations that are outwardly hostile to the sciences of psychiatry and psychology. These groups deny that mental illness exists, claiming there is nothing out-of-the-ordinary when an individual hears voices or experiences extreme mental states--and that these should be celebrated as nature's gifts to mankind, contributing to artistic creativity and human diversity. Leaders of these organizations--including at least one of which SAMHSA has elevated to the status of a ``National Technical Assistance Center'' and received at least $300,000 in taxpayer dollars the past year--have actively encouraged supporters to ``Occupy'' the 2012 annual convention of the American Psychiatric Association--decrying the professional association's role in developing the Diagnostic and Statistical Manual of Mental Disorders, or DSM. ``Psychiatric labeling,'' they say, is ``a pseudoscientific practice of limited value in helping people recover.'' When SAMHSA-funded organizations are not busy encouraging those with mental illness to go off their prescribed medications or destroying trust between individuals with serious mental illness, their family caregivers, and their physicians, these taxpayer-backed groups are actively lobbying against effective evidence-based treatment like Assisted Outpatient Treatment (AOT) laws--a less restrictive alternative to involuntary commitment. Numerous academic studies have shown AOT to be incredibly effective in reducing re-hospitalizations and re-arrests among, until-then, untreated individuals with serious mental illness. As an agency of the U.S. Public Health Service, we expect SAMHSA's work to be firmly rooted in evidence-based practices, enduring high-level scientific peer review at the hands of licensed mental health professionals. Perhaps some of it is but much of it appears to fall far short of such standards. To get answers to our questions, this morning we will hear from Pamela Hyde, the Administrator of SAMHSA since 2009, on our first panel. On our second panel, we will hear from E. Fuller Torrey, a psychiatrist and long-time observer of SAMHSA; Dr. Sally Satel, a member of the National Advisory Council to SAMHSA's Center for Mental Health Services for four years; and Joe Bruce, a family man from Caratunk, Maine, whose life was irrevocably changed by one SAMHSA program in particular. Joe's wife, Amy, was murdered by their son, Will, only months after being released from a psychiatric center where he had been treated for schizophrenia. Reflecting on this horrific act several years ago, Will noted that, un-medicated at the time, he believed he was a clandestine operative under orders to kill his mother, an Al Qaeda operative. Joe believes the efforts of a SAMHSA-funded organization obtained his son's premature release from the hospital without putting in place a mechanism for ensuring that Will would remain on his medications. Joe--we extend our condolences to you and your family, and thank you for sharing your moving story with us today. We will also hear from Dr. Joseph Parks III, Chief Clinical Officer of the Missouri Department of Mental Health, who has substantial experience working with SAMHSA grant funded- projects. Thank you to all our witnesses today. # # # Mr. Murphy. I would now like to give the ranking member an opportunity to give remarks of her own. OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF COLORADO Ms. DeGette. Thank you very much, Mr. Chairman. Your passion about this issue is evident. We appreciate everything that you are doing to have these hearings on mental illness and gun violence. I want to join you in welcoming all of our witnesses here today and looking forward to hearing your perspectives on SAMHSA. As we all know, Congress has directed SAMHSA to provide services to prevent, treat, and recover from mental health and substance abuse disorders. The Agency administers a number of funding streams, including competitive, formula, and block grant programs. It also collects data on mental illness, behavioral health, and substance abuse. Chairman Murphy and I have been working together to identify areas where, on a bipartisan basis, we can agree to commonsense solutions. And in his opening statement, the chairman has identified a number of important issues regarding SAMHSA that we need to work together to address. Some of those criticisms I think really do merit this committee's consideration. Other criticisms that we see out in the world only distract us from our real purpose, which is to ensure that we identify people who are living with mental illness before crisis situations arrive and make sure that they can get the mental health treatment that they so desperately need. For example, we will hear that SAMHSA is too focused-- actually, we did hear in the chairman's opening statement that SAMHSA is too focused on substance abuse programs, not dedicated to addressing serious mental illness. And in fact, mental health programs account for 27 percent of SAMHSA's overall budget in fiscal year 2013 and substance abuse comprises 68 percent of its budget. And so if this is really a legitimate problem that is leading towards a lack of addressing serious mental health issues, then it is Congress' responsibility to fix that. Every year, Congress determines through the appropriations process what SAMHSA spends on mental health versus substance abuse. And so if Congress wants SAMHSA to focus more on mental health, we should work together to provide the Agency with more resources to do so. And I look forward to working with the chairman and the rest of the members of this committee to make that happen as the appropriations process develops this spring. I also would be happy to work with the chairman and everyone on this committee to ensure that the Agency has the resources it needs to do the job and that we enact legislation that guarantees that we actually fund the programs that we think are important. Another criticism that we have heard and I agree with it is that we don't have enough data to know what programs SAMHSA funds are working well with and what are not, but you will not find a bigger advocate in Congress for science-based research than me. I have been fighting for it in every area for decades: abstinence-only sex education, stem cell research, on and on and on. And if we want these programs to work, they have to be science-based. And so what we need to do is make sure that SAMHSA, States, and other grantees have clear reporting requirements and metrics so that in fact we can measure what worked and what doesn't work and that we can measure progress. And so I am hoping, Mr. Chairman, that we can work together on this, too, improving SAMHSA reporting requirements and figuring out on an evidence-based basis what really works. Now, I just want to raise one concern about these hearings. This is the third proceeding on mental health, and for the third time we don't have a witness appearing to provide the perspective of people who are living with mental illness. We discussed this the other day. We keep talking about issues that affect their daily lives. We keep having providers and family members and others coming in to talk about people with mental illness but we haven't had people who have mental illness directly talk to us, and I think there are people who would be willing to come forward and talk about their concerns and their issues, which of these SAMHSA programs work for them, which of them don't work for them. What about the privacy provisions and what about the everything, the funding and everything? So I am hoping in our next hearing we could have a panel of people who have mental illness to talk about from their perspective what works and doesn't work. Finally, as we discuss ways in which SAMHSA invests in the prevention and treatment of mental illness in this country, I think that it is important that we do not lose sight of the key role recently enacted legislation plays in advancing our shared goal of improving access to mental health services for the millions of Americans experiencing mental illness. The Mental Health Parity Act--which Chairman Murphy and I both cosponsored along with a number of other members of this committee--ensures that group health plans and ensures offering mental health and substance use disorder benefits do so in a manner that is comparable to coverage for general medical and surgical care. The Affordable Care Act, building on this parity legislation, will expand mental health and substance use disorder benefits and parity protections for 62 million Americans. The implementation of the Affordable Care Act and continued support of SAMHSA programs that work will go a long way in ensuring that people with serious mental illness have access to the treatments they need. I yield back, Mr. Chairman. Thank you for your comity. Mr. Murphy. I thank the gentlelady for her comments. Now turning to the chairman of the full committee for 5 minutes, Mr. Upton. OPENING STATEMENT OF HON. FRED UPTON, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MICHIGAN Mr. Upton. Well, thank you, Mr. Chairman. Today, we are here to examine the role of the Substance Abuse and Mental Health Services Administration (SAMHSA) in delivering services to the severely mentally ill, and I certainly appreciate the chairman's interest, passion, and professional insight regarding this issue. In the wake of the tragic shootings at Sandy Hook, this subcommittee has stepped up to examine an important question: what is the federal government doing to address serious mental illness? And I commend the chairman for leading this investigation. While the vast majority of individuals with a mental health condition are nonviolent, in March, the Subcommittee learned from Dr. Tom Insel, Director of the NIH, National Institute of Mental Health, the important fact that treatment can reduce the risk of violent behavior 15-fold in persons with serious mental illness. This morning, we direct our attention to the primary federal agency responsible for supporting community-based treatment services for mental illnesses. With an annual budget of nearly $1 billion, SAMHSA's Center for Mental Health Services could serve as a key part of the Federal Government's efforts to address the tragic impacts on our society of such serious mental illnesses as major depression, schizophrenia, and bipolar disorder. This includes connecting these individuals with effective treatments at a time when 40 percent of adults with serious mental illness report not receiving any treatment at all. Not doing so increases the chances that the next James Holmes or the next Adam Lanza will in fact fall through the cracks. Unfortunately, I am concerned that SAMHSA may not be directing those dollars to treat those with the most severe of mental illnesses. Further, I am also concerned about the commitment to science and the scientific process--including psychiatry--displayed by several major grant recipients. We need to be investing our dollars in the programs with the best record for treating those who have mental illnesses. [The prepared statement of Mr. Upton follows:] Prepared statement of Hon. Fred Upton Today we are here to examine the role of the Substance Abuse and Mental Health Services Administration (SAMHSA) in delivering services to the severely mentally ill. In the wake of the tragic shootings at Sandy Hook Elementary School in Newtown, Connecticut, this subcommittee has stepped up to examine an important question: what is the federal government doing to address serious mental illness. I commend Chairman Murphy for leading this investigation. While the vast majority of individuals with a mental health condition are nonviolent, in March, the subcommittee learned from Dr. Tom Insel, Director of the National Institute of Mental Health, the important fact that treatment can reduce the risk of violent behavior fifteen-fold in persons with serious mental illness. This morning, we direct our attention to the primary federal agency responsible for supporting community- based treatment services for mental illness. With an annual budget of approximately $1 billion, SAMHSA's Center for Mental Health Services could serve as a key part of the federal government's efforts to address the tragic impacts on our society of such serious mental illnesses as major depression, schizophrenia, and bipolar disorder. This includes connecting these individuals with effective treatments at a time when 40 percent of adults with serious mental illness report not receiving any treatment. Not doing so increases the chances that the next James Holmes, the next Jared Loughner, and the next Adam Lanza will fall through the cracks. Unfortunately, I am concerned that SAMHSA may not be directing those dollars to treat those with the most severe of mental illnesses. Further, I am also concerned about the commitment to science and the scientific process--including psychiatry--displayed by several major grant recipients. We need to be investing our dollars in the programs with the best record for treating those who have mental illnesses. As the experts joining us today, including Doctors Torrey and Satel will share with us, SAMHSA's programs do very little for those at the extreme end of the spectrum of mental illness, who lack awareness of their own condition, who deny that they have a disorder demanding treatment, and who see no reason to follow a medication regimen. I want to especially thank our witness, Joe Bruce, for joining us today to share his family's tragic story. I also welcome Administrator Hyde and look forward to hearing about her agency's plans to address these concerns about the most vulnerable among our nation's mentally ill. # # # Mr. Upton. And at this point I will yield the balance of my time to Dr. Burgess. Mr. Burgess. I thank the chairman for yielding. You know, the recent notorious tragedies have brought to light the challenges that are faced by those suffering from mental illness today in the United States. Certainly SAMHSA has an important role as the point agency to address mental health issues, but out of their budgets there are questions that have come up about the lack of oversight and accountability. Is it in the public's interest to use limited SAMHSA funding to encourage alternate approaches to treating mental illness? Is it the best use of their funding to support an organization that lobbies against programs that encourage proven treatment methods such as psychiatric medication adherence? And now, we are going to hear from witnesses in the second panel who raised serious questions about the use of the funding to commission oil paintings and providing for an annual staff musical within the agency. This agency is responsible to use its resources to ensure that the almost 10 million Americans with mental illness can be productive members of society. It is our job on the committee to assess both the successes and the shortfalls of the Agency to determine where the Agency's resources can be used most effectively and ensure they are doing their best job. I look forward to hearing about that today and I will yield the balance of the time to Dr. Gingrey. Mr. Gingrey. I want to thank you again, Mr. Chairman, for your leadership on this important issue. I want to thank Dr. Burgess as well and highlight one particular perspective that is often overlooked: adherence to a planned treatment. All too often, individuals suffering from mental illness, substance abuse disorders, or both are under the treatment of a qualified medical professional. They have been prescribed an appropriate regimen of medicine, yet they struggle to take their medication consistently. This results in relapses and, of course, disease progression. As you know, relapses result in significant suffering, increased cost to the patient and the healthcare system, and in some cases, violent, criminal behavior. Mr. Chairman, as we seek today to highlight the most efficient use of federal resources for this particular vulnerable population, I believe that improving adherence, whether by novel drugs or innovated management of the disease, is particularly important and I look forward to working with the Subcommittee to pursue policies particularly at SAMHSA to ensure the best possible treatment options available to providers and patients confronting mental illness and substance abuse in order to improve health and health economic outcomes. Mr. Chairman, thank you for your patience and I yield back. Mr. Murphy. The gentleman yields back. I now recognize for 5 minutes Mr. Butterfield. OPENING STATEMENT OF HON. G.K. BUTTERFIELD, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NORTH CAROLINA Mr. Butterfield. Let me thank you, Mr. Chairman, for yielding time. I thank the ranking member, Ms. DeGette, for her comments and I want to associate myself with each word that she uttered a few minutes ago. She is exactly correct. I thank the chairman of our full committee, Mr. Upton, and all of you who have a profound interest in the subject. This is a very, very important subject not just in my congressional district but throughout the country. Let me say good morning to the witnesses and thank you so very much for coming today to be a part of this process. Funding from the Substance Abuse and Mental Health Services Administration--and we call it SAMHSA--has helped my State enormously. It has helped probably every State in the country but I can speak specifically to my State. For fiscal year 2012 my State of North Carolina received $20 million from Mental Health Services. And if my colleagues will check, you will see that there has been significant federal investment with this population all across the country. It is a good program. It is a valuable program. In my congressional district, the Durham County Health Department, for example, received funds to enhance services and support available to 16- to 21-year-olds with serious mental health issues and their families. Also, the Child and Parent Support Services, Incorporated, in Durham received funds to assist clinicians working with child welfare and even military families. But we continue to see cost-cutting measures like sequestration and the Ryan budget which endanger important programs like those in Durham and throughout my State and throughout the country. There is an article this morning in the Hill Newspaper that even warns of round two of sequestration. So many of our citizens think that sequestration was a 1-year proposition, but it is a 9-year proposition and now we are getting ready for round two. And Mr. Chairman, we have done absolutely nothing to fix sequestration. I support full repeal of sequestration. Mr. Chairman, the 2013 spending plan that SAMHSA released earlier this month shows that the sequester will result in cuts of over $200 million in SAMHSA funding this year, a cut of almost 6 percent, and next year, it would certainly be more. Every single SAMHSA program will be affected. Our citizens need to know that. Every SAMHSA program will be affected. The Mental Health Block Grant Program is being cut by $23 million. Children's mental health services are cut by $6 million. Suicide prevention funds will be cut; programs to help the mentally ill people who are homeless will be cut. This will mean fewer SAMHSA grants and fewer people with access to mental health services. Mr. Chairman, we must continue to support those struggling with mental illness and their families by continuing to strengthen these very important programs. At this time, I will yield the balance of my time to the gentlelady from Florida. Ms. Castor. Well, I thank my colleague for yielding and I thank the chairman and the ranking member for calling this very important hearing. It is vital that this committee provide oversight of the mental health services provided by the Federal Government in partnership with state and locals and for families. What I hear consistently from families and mental health professionals at home is simply that the needs so far outstrip the resources that are available to families and professionals today. That point was made by Ranking Member DeGette, and she is right. For example, just yesterday, I had about 10 emergency room physicians, fairly new doctors, pay a visit up here on Capitol Hill and our conversation got to the point of what they do every day when they are confronted with some of our neighbors who have mental health issues, and they made a point again, there simply aren't enough places for people to receive counseling and treatment. They said just what we know, one of the real problems is the laws say unless someone is a danger to themselves or to others, they are going to be discharged. And that is simply not going to help us address the needs of our families. This is similar to what I hear from school districts, teachers, and families and schools. They know when young children have issues and there are great counselors out there but significantly not enough to provide the basic treatment and counseling that they need to make sure that they are healthy and can succeed in school. So we need to focus on what works in our community. I hope we will be able to address that today. The answers are different for the Tampa Bay area than they are from rural areas across the country, but what we have in common is that the needs far outstrip the resources available. And Mr. Chairman, at this time, I would like to ask unanimous consent to place into the record Ranking Member Waxman's statement for this hearing today. Mr. Murphy. Without objection, thank you. We have a copy of that now. Thank you. [The prepared statement of Mr. Waxman follows:] Prepared statement of Hon. Henry A. Waxman Mr. Chairman, I want to thank our witnesses for coming today. I appreciate Administrator Hyde being here, and I want to particularly thank Mr. Bruce for traveling here to share his tragic story. I appreciate his bravery in joining us. His story--and those we've heard from other families--is a powerful reminder of why this Committee needs to act to improve mental health services and treatment. Mr. Chairman, I know how important this issue is to you. And I know that you are serious about improving mental health care in this country. But I do worry about our progress. After the tragic Newtown massacre, I was hopeful about efforts to improve the mental health care system and make sure that those suffering from serious mental illnesses received the diagnoses and treatment that they need. Six months later, I am much less confident. Since Newtown, Congress has done nothing to advance mental health proposals. In fact, we've lost ground. Last week, the House voted to repeal the Affordable Care Act--the law that builds on bipartisan mental health parity efforts to extend mental health and substance use disorder benefits and parity protections for 62 million Americans. And we have done nothing to fix sequestration, which represents a major reversal of progress. Mr. Chairman, the 2013 spending plan that SAMHSA released earlier this month shows that the sequester will result in cuts of over $200 million in SAMHSA funding this year--a cut of almost 6%. Every single SAMHSA program will be affected. The Mental Health Block Grant program is being cut by $23 million. Children's Mental Health Services are cut by $6 million. Suicide prevention funds will be cut. Programs to help mentally ill people who are homeless will be cut.This will mean fewer SAMHSA grants and fewer people with access to mental health services. According to Mental Health America, the sequester will mean that more than 1 million children and adults will be at risk of losing access to any type of public mental health support . almost 30,000 mentally ill, homeless people will lose access to primary care referral, housing assistance, and other important services . more than 11,000 professionals will lose access to youth suicide prevention training . and more than 1,500 at-risk youth will not be screened for mental health conditions. The list goes on and on. These cuts are mindless. They represent an enormous step backward in our efforts to prevent, diagnose, and improve treatment for those with mental illnesses. And they are happening as we speak. Mr. Chairman, this Committee needs to act. The sequester is creating a slow-motion crisis for those with mental illnesses, and we need to work together to end it. But we should not only end the sequester--we should work together to strengthen our laws and improve funding so those suffering from serious mental illnesses are identified, receive better services, and achieve better outcomes. This Subcommittee has done important work. Through our series of briefings, forums, and hearings, we have learned about what works and what doesn't, and where the funding and legislative gaps exist in our nation's mental health care system. Now, Mr. Chairman, it's time for us to act together, in a bipartisan way, to fill those gaps and chart a new course in the provision of mental health services for those in need. I look forward to working with you and my colleagues to achieve those goals. Mr. Murphy. All right. I would now like to introduce the witness on the first panel for today's hearing. Our first witness is Pamela Hyde. She was nominated by President Barack Obama and confirmed by the U.S. Senate in November 2009 as administrator of the Substance Abuse and Mental Health Services Administration. Ms. Hyde is an attorney and comes to SAMHSA with more than 35 years of experience in management and consulting for public health care and human services agencies. She served as a state mental health director, state human services director, city housing and human services director, as well as CEO of a private nonprofit managed behavioral healthcare firm. Welcome today, Ms. Hyde. Now, I will swear you in. As you are aware, the Committee is holding an investigative hearing. When doing so, we have the practice of taking testimony under oath. You have any objections to testifying under oath? Ms. Hyde. No, sir. Mr. Murphy. And the chair then advises you that under the rules of the House and rules of the Committee, you are also entitled to be advised by counsel. Do you desire to be advised by counsel during your testimony today? Ms. Hyde. No, thank you. Mr. Murphy. You probably can provide that for yourself then. In that case, if you would please rise and raise your right hand, I will swear you in. [Witness sworn.] Mr. Murphy. Thank you. You are now under oath and subject to the penalties set forth in Title XVIII, Section 1001 of the United States Code. You are now welcome to give a 5-minute summary of your written statement, Ms. Hyde. TESTIMONY OF PAMELA S. HYDE, ADMINISTRATOR, SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION Ms. Hyde. Thank you, Congressman Murphy and Ranking Member DeGette, for holding this hearing today. It is an important conversation and I am sure, as you are aware, you have already stated you know that SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities. I would like to take just a few moments to remind you that SAMHSA is a small agency with a very big mission. While our funding is small, we use every opportunity to impact the public and private funders of mental health services. We collaborate and influence our sister agencies in HHS and across Federal Government, and we work with States, tribes, territories, communities, and stakeholders to help advance the behavioral health of the Nation. SAMHSA has many roles. Funding is one of them but it is not the only one. We also provide leadership and voice for and about behavioral health issues, and that includes substance abuse. It also includes mental illness. It includes prevention, treatment, and recovery. We also do surveillance and data reporting. We provide funding, as we indicated, and we also work to improve practice with a number of materials and trainings, and we look at evidence-based practices, as well as practices coming to science. And we provide information to the public in the field, our public awareness and education responsibility, and we also have some responsibility for setting standards and regulations in certain areas. I want to just make a quick comment about mental health financing because it goes to SAMHSA's role. The mental health spending for mental illness in our country was only about 6.3 percent of all health spending in 2009. That is far below the importance of mental health and mental illness in our healthcare issues. Mental health treatment spending depends much more on public payers than other kinds of health spending, about 60 percent of mental health spending compared to 49 percent of all health care spending. For public spending, Medicaid and Medicare are by far the largest payers for services, and when you add their 40 percent to about 26 percent of private insurance, then insurance-- Medicaid, Medicare, and private insurance--accounts for about 2/3 of mental health spending followed by state and local governments' out-of-pocket spending and then a small portion of federal spending, and that is where SAMHSA's dollars are. So our dollars are a fairly small part of that larger overall effort. About 29 percent, as it was indicated earlier today, is SAMHSA's--it is about $3 billion--3 plus billion dollars, about 29 percent of it is for mental health. About 70 percent of it is for substance abuse. Of our mental health dollars, about 27 percent of our total budget is for mental health services, about 2 percent, give or take, is for surveillance data, public awareness, and other kinds of efforts. This distribution between substance abuse and mental health issues has been about the same for the last 5 years. Within the mental health budget of SAMHSA, about half of it is block grant services, which is specifically for people with serious mental illness and young people with serious emotional disturbance, and the balance of SAMHSA's mental health budget provides support for a range of mental health prevention, treatment, and recovery support services, all as directed by Congress. Altogether, SAMHSA's mental health budget is spent on about--75 to 80 percent of it is spent on adults with SMI or children with SED, or serious emotional disturbance. Congress has made significant investments as well in the prevention, emotional health development, and promotion in early intervention for mental health issues, and SAMHSA does administer some of those programs. In a very short time that I have left, I just want to highlight a couple of programs. Our Mental Health Block Grant of course is about half of our mental health spending. It is a flexible but critical, important part for the States that primarily serves people with evidence-based approaches who are not otherwise covered by insurance or other efforts and who--or the services are not otherwise covered. So Medicaid, Medicare, private insurance may pay for the basics like medication, inpatient, those sorts of issues. The Mental Health Block Grant often supplements those services with other important and evidence-based approaches. We also have some approaches such as our Children's Mental Health Initiative. It is a huge part of our program that has since 1994 served over 122,000 young people with serious emotional disorders with great results. We also have a program at about $43 million that is the National Child Traumatic Stress Network, and it has been in existence for about 10 years and has provided evidence-based approaches to dealing with young people with trauma. Our Primary and Behavioral Health Integration Program is a program explicitly focused on the health of adults with serious mental illness and we have had major improvements in the health impacts for those individuals in that program. We also have a program for assistance for transition from homelessness, which primarily serves adults with serious mental illness or people with mental illness and co-occurring disorders who are homeless. We also have a Youth Violence Prevention Program that Congress has provided resources for us to work on, and that federal grant program is designed to prevent violence and substance abuse among our Nation's youth, schools, and communities. We do a lot of that work in conjunction with education. We also have a major program, about $33 million, called LAUNCH, which is specifically for children aged 0 to 3-- to 8 to try to work on prevention, early intervention. We also do--and I want to make a point here because of what is going on in Oklahoma right now that one of the major issues that SAMHSA works on is disaster response and preparedness. So whether it is Tucson, Sandy Hook, Aurora, or major disasters and weather-related emergencies such as Oklahoma, we do a lot of response. Mr. Murphy. Sorry. If you could give your wrap-up now. Ms. Hyde. I think I will end there and let you ask questions. Thank you very much. [The prepared statement of Ms. Hyde follows:] [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] Mr. Murphy. Thank you so much for being here today and for your work. I want to just clarify a couple things. I note your testimony in written and oral states several times that SAMHSA supports evidence-based programs and practices and even data- driven solutions. So does this mean SAMHSA requires evidence and data before making a grant award? Ms. Hyde. Congressman Murphy, thank you for the question. Yes, we require in our request for applications we ask individuals either to use an evidence-based practice that we have identified or to tell us what approach they propose to use and to explain to us how they think that it has evidence behind it or how it is moving into science as they are developing evidence of it working for them. Mr. Murphy. Do you use models like NIH has where there are professionals, experts in the field with advanced degrees who are the majority of panelists to review grants? Ms. Hyde. That is correct. We use experts to do those reviews. Mr. Murphy. By experts, I mean people with MDs or PhDs who have the scientific credentials as the majority of panelists in each grant review? Ms. Hyde. Each of the grant reviews use people who are experienced in that area. What their degrees are, I don't have that in front of me. Mr. Murphy. Experience, I am talking about the majority of the panelists. This is a yes or no. Are the majority of panelists people who have specific advanced training and academic and professional credentials in those fields versus just experience? Ms. Hyde. They have training and experience. I do not have with me what their degrees are. Mr. Murphy. I am just asking is the policy of SAMHSA that the majority of people reviewing grants have advanced degrees and academic credentials and license credentials in reviewing these grants? Ms. Hyde. It is our policy, Congressman, to have individuals with the experience and---- Mr. Murphy. But that is a no? It sounds like---- Ms. Hyde. I will repeat---- Mr. Murphy [continuing]. That is a no. Ms. Hyde [continuing]. That I don't have with me and I don't have the information about what their degrees---- Mr. Murphy. OK. That would be a major issue because that is a major part of your work. Do you fund competitive or discretionary grants that are part of the mission of SAMHSA or do you also fund grants that run diametrically opposed to the mission of SAMHSA? Ms. Hyde. I think all of our grants and all of our efforts, whether grant-based or not, are working toward our mission. Mr. Murphy. OK. Thank you. What is the evidence that SAMHSA used to fund an advocacy group that encourages the mentally ill not to take their medication? Ms. Hyde. I am sorry, Congressman. Can you repeat the question? Mr. Murphy. I just wonder what evidence did you use as the decision-making process when you fund advocacy groups that encourages the mentally ill not to take the medication? Ms. Hyde. I don't think we fund advocacy efforts explicitly to tell people not to take the medication. Mr. Murphy. You just told me that you don't fund things that run counter to your mission, and we will here today from people who have evidence that SAMHSA does fund organizations that encourage people not to take their psychiatric medication. So I am just wondering what the evidence is that SAMHSA relied upon to fund such a grant. Ms. Hyde. We fund lots of organizations who have missions or who have opinions or value bases that may not necessarily agree with SAMHSA or with the field. What we fund are specific grants for specific purposes related to the mission of SAMHSA. Mr. Murphy. I still want to know, and we are going to continue to pursue this because it is an important issue. And I note in your testimony you do not even mention the title psychiatrist, and as I noted in my opening statement, you don't mention the words bipolar, schizophrenia, or other forms of severe mental illness to talk about a lot of things. And many of those things are good, but we are here today to talk about severe mental illness. Does SAMHSA acknowledge that there was a scientific evidence basis provided by SAMHSA's sister public health agencies such as NIH and the FDA that support the effectiveness of medical treatment for mental illness? Ms. Hyde. Absolutely, Congressman. We work closely with NIMH, with NIDA, with NIAAA, with other institutes within NIH, with FDA, and other agencies and we work hard to take what they learn from the research and use it in the efforts that we do. Mr. Murphy. One of those that you fund is the National Empowerment Center whose director espouses anti-science, anti- psychiatry views and your agency also funds the alternatives, which is that in your workshop or symposium which regularly features workshops and speakers who advised people with serious mental illness to go off physician-prescribed medication. And as I said before, your testimony today does not even mention the psychiatry or get into medication issues. So I once again want to know where is the evidence that this approach to treating severe mental illness has any scientific, evidence- based, data-driven background that would support what you continue to fund? Ms. Hyde. Congressman, there are a number of ways to provide treatment and services, and we fund a number of conference efforts and others. We do not go inside each individual presentation to identify whether or not we agree with each individual---- Mr. Murphy. But you continue to fund it---- Ms. Hyde [continuing]. Presenter---- Mr. Murphy [continuing]. And you oftentimes speak at an opening or part of those conferences? Ms. Hyde. Yes, we do, and we fund other conferences for the American Psychological Association, for ASAM, for other organizations also that we don't look at every single presentation---- Mr. Murphy. I mean yes or no, is it medically possible to prevent the onset of schizophrenia? Ms. Hyde. I think the biomarkers are not there yet. I think NIMH is working hard on biomarkers about that. We know that we can prevent a lot of the salient conditions about schizophrenia and we know that there are a number of people with schizophrenia who can in fact get to a point where they are living without the symptoms of the illness that they first experienced. Mr. Murphy. Thank you. Thank you. Ms. DeGette, 5 minutes. Ms. DeGette. Let try to clear some of this up, Administrator Hyde. It is not in the mission of SAMHSA to tell patients not to take their medication, is that correct? Ms. Hyde. That is correct. We---- Ms. DeGette. OK. So what happens is Congress has mandated that some of the groups that SAMHSA fund are patient advocacy groups, correct? Ms. Hyde. That is correct. Ms. DeGette. And some of those patient advocacy groups may in fact tell their people not to take drugs, is that correct? Ms. Hyde. They very well may. Ms. DeGette. And that is not SAMHSA's policy; that is those groups' policy, right? Ms. Hyde. Those groups may have that policy. Ms. DeGette. And so really Congress should look at do we want to be telling SAMHSA to fund patient advocacy groups, right? Ms. Hyde. It is certainly a congressional authority and a congressional program---- Ms. DeGette. The other issue is a great amount of the money that SAMHSA spends is block granted to the States, is that right? Ms. Hyde. That is correct. Ms. DeGette. And so once those funds go to the State, then the governors decide how those funds are going to be spent and SAMHSA doesn't really exercise discretion over the groups that the States give those block grants to, right? Ms. Hyde. That is correct. We have a plan that the State provides to us---- Ms. DeGette. Right. Ms. Hyde [continuing]. But the State makes that decision. Ms. DeGette. Right. So that is, again, something else Congress should look at is do we really want to be just sending that money to the States without the scientific control of where those funds go, right? Ms. Hyde. Correct. And we do ask them to do evidence-based practices and data-driven processes. Ms. DeGette. Of course you do. Now, let me ask you this because you talked quite a bit in depth in your opening about the percentages of SAMHSA's budget that go to mental health versus drug control and so on, and that again Congress has made those requirements on SAMHSA, right? Ms. Hyde. That is our---- Ms. DeGette. I mean, it is not you that sits there and says I am going to spend 27 percent of my money on serious mental health; it is Congress that says that, right? Ms. Hyde. That is correct. Ms. DeGette. OK. Now, I read the testimony of the second panel and some of those witnesses--I am sure you have read it, too--they have strong criticisms of SAMHSA and I want to ask you about it. Dr. Torrey says that serious mental illness has a very low priority at the Agency because in the 3-year planning document that you have, there is no mention of a number of conditions. So I want to ask you a question. Does the Agency have a very low priority for serious mental illness? Ms. Hyde. No. As I indicated, about 75 to 80 percent of our mental health dollars go towards substance abuse--I mean, excuse me--toward serious mental illness and serious emotional disturbance. Ms. DeGette. And so why in that document did you not specifically mention schizophrenia, schizoaffective disorder, bipolar, severe depression, or obsessive compulsive disorder. Ms. Hyde. That planning document is about behavioral health systems and directions that we are taking and it has to do with developing quality frameworks and developing public awareness and approaches. It has to do with prevention and a number of other things. We don't have any references to any diagnoses in that particular---- Ms. DeGette. Oh, I see. OK. So it is just because of the nature of that document---- Ms. Hyde. That is correct. Ms. DeGette [continuing]. Not because there is not an emphasis. Now, Dr. Torrey also says--and this is a quote from his testimony--``nobody among SAMHSA's 574 staff has experience in severe mental illness.'' Is that true? Ms. Hyde. No. Ms. DeGette. Why do you say that? Ms. Hyde. Because we have a number of people ranging from social work, psychologists, internists and others who work-- have been working in this field for years in these areas, so they have extensive experience. Ms. DeGette. And now, is it true that SAMHSA has only employed one psychiatrist? Ms. Hyde. We don't employ a lot of psychiatrists. We are not the direct provider of services like IHS or others. We did actually just announce this week--we have been working on it for 2 years--we announced the arrival on June 3 of our chief medical officer, who is a psychiatrist and will be joining---- Ms. DeGette. So what you saying is because you are not focusing on actual treatment, you don't feel you necessarily need people with those credentials for every position? Ms. Hyde. Not for every position---- Ms. DeGette. OK. Ms. Hyde [continuing]. Absolutely not. Ms. DeGette. Now, I want to ask you what is the impact on SAMHSA's budget by the sequester and what are you anticipating for fiscal year 2014? Ms. Hyde. The sequester results in about $168 million reduction in our programs. It was required that we take it across all programs so it didn't matter which ones. We had to take it against all of them. We expect or anticipate that that will result in about 330,000 less people getting services---- Ms. DeGette. Wow. Ms. Hyde [continuing]. And the benefits of SAMHSA's programs. So it will significantly reduce that. For 2014 the President's budget proposes to undo the sequester and so to take us back to a point where we have more funding for services and programs, and he also proposes new funding and services as a result of what we have learned in our efforts out of the Sandy Hook effort. Ms. DeGette. Thank you very much. Mr. Murphy. I recognize the gentleman from Texas, Dr. Burgess, for 5 minutes. Mr. Burgess. I thank the chair for the recognition. I am sorry I had to step out for a moment. I had a group of doctors out there I was talking to. But it brings up a good question. How many people work in your agency? Ms. Hyde. Congressman Burgess, about 600 people, give or take. Mr. Burgess. And of that cadre of 600 individuals, how many M.D. psychiatrists are working? Ms. Hyde. We have one. We also have a number of---- Mr. Burgess. I found one on the internet, so good, we are aligned. Ms. Hyde. We just announced the arrival on June 3 of our chief medical officer, which we have been seeking for a couple years. She arrives and will start and she is a psychiatrist in addiction psychiatry, board-certified. Mr. Burgess. So if I have it correct, I mean you are the mental health agency and substance abuse agency for the entire country, and up until a week or two ago, you had one psychiatrist on your staff? Ms. Hyde. As I said--you might have been out of the room, but I did say that, yes, we don't do direct services. That is not what our charge is so we have a number of psychologists, social workers, counselors, other behavioral health professionals, addictionologists, and others in addition to other professions that we need to do our work. Mr. Burgess. Yes, but just speaking from someone who has spent a life in clinical practice, I mean, there is no substitute for that. Yes, I am in a position now where public policy is all that I think about, but at the same time, it is that time spent in the clinical practice of medicine that informs the policy, and your agency, it just strikes me we are really thin there. Is that a fair assessment? Ms. Hyde. Given what our charge is and what we do and to be quite honest with you what we are able to pay, we have had a difficult time achieving any higher percentages of those individuals. We do have internists and others who work in other areas where it requires that kind of clinical expertise in order to do the program. We have, as I said earlier, a number of other behavioral health professionals who do work in our grant programs, and then we have people like statisticians and accountants and others who do other parts of our programs. Mr. Burgess. And all those people are important, but again, I would just submit that there is no substitute for someone who has spent time in the clinical realm of practicing medicine. I am not a psychiatrist but I know that because of that time in clinical medicine, someone who has practiced psychiatry is going to be invaluable to your agency as far as informing the policy and one or two folks aren't going to get it in an agency as large as yours with the enormous footprint that you have in the country as regards to mental health services. Now, I accept the part about psychiatrists are expensive. I have always thought they have been overvalued, but we can get into that discussion later on. But, you know, you are talking now about you need to train additional people in the mental health services, correct, in SAMHSA? Ms. Hyde. In conjunction with HRSA, that is correct. Mr. Burgess. And about how many? Ms. Hyde. The President's proposal for 2014 would produce about 5,000 more professionals. Mr. Burgess. And of that 5,000 what is the cohort of clinical psychiatrists that would be part that? Ms. Hyde. In that particular cohort, that is not what it is directed towards. HRSA's programs are directed more toward those clinical-level individuals. Mr. Burgess. Well, with all due respect to the President, he has never practiced clinical medicine either and I think that is apparent from the state of healthcare in this country today. But nevertheless, you need to have the expertise of someone who has accepted the responsibility for diagnosing and treating patients, following through on a treatment plan, and lacking that, it is hard to know how to advise you to do your job better. Without the basic tool, without that basic person involved at the clinical level, I just don't know how you deliver on the promise that you are supposed to do. Now, my understanding is that years and years and years ago Congress in its wisdom separated out the research side from what you do, is that correct? Ms. Hyde. That is correct. Mr. Burgess. So the research goes on at the National Institute of Health, but without a clinical psychiatrist on the staff, it is hard for me to know how you are going to be able to evaluate those things that are developed by that great research institution up north of town and make them applicable to the people who are suffering that you are supposed to be taking care of. Ms. Hyde. Well, I have two comments about that, as I said earlier, we spent a couple of years and finally were able to recruit a new clinical psychiatrist to be the chief medical officer to do that kind of consultation. We also work very closely with Tom Insel and all of his staff at NIMH on issues about clinical care and about evidence-based practices. Mr. Burgess. Well, look, the President has announced a big brain mapping initiative, but without the people there to deliver the goods, I am afraid it is an empty promise. Mr. Chairman, thank you. I will yield back. Mr. Murphy. Mr. Butterfield, you are recognized for 5 minutes. Mr. Butterfield. Thank you very much, Mr. Chairman. And I am going to try to get through this very quickly. Again, thank you for your testimony. Let's talk a little bit about sequestration. You mentioned it just a few moments ago. Did I understand you to say that it is had a $168 million impact on your agency? Ms. Hyde. That is correct. Mr. Butterfield. That is in fiscal year 2013? Ms. Hyde. Correct. Mr. Butterfield. And what is the projection, if you know, for 2014 and beyond? Ms. Hyde. I don't know explicitly. My understanding is that it would probably result in somewhere like another 2 or 2-1/2 percent reduction but we don't have those numbers finalized. Mr. Butterfield. And that translates into some 300,000 people or more? Ms. Hyde. Just for 1 year, correct. Mr. Butterfield. All right. Now, the House Labor HHS Appropriations Subcommittee has proposed an 18 percent cut. Are you aware of that? Ms. Hyde. I have heard that. Mr. Butterfield. And that translates into some $624 million. What impact would that proposal have on providing care to individuals with serious mental health illness? Ms. Hyde. Well, it would--Congressman, it would have a profound impact. Just on our agency alone it would have a profound impact, not to mention on all the other agencies that provide services. Mr. Butterfield. The Affordable Care Act has provided young adults with access to health insurance through their parents' plans, and that is a good thing, and it will provide people with access to health insurance in 2014 when the exchanges actually go into effect. With the full implementation of the Affordable Care Act in 2014, will it increase the ability of people to access mental health care? Ms. Hyde. Absolutely. And about 62 million people will have access to coverage for mental and substance abuse disorders that don't have it now by a combination of the Affordable Care Act and the Mental Health Parity and Addiction Equity Act. And of those 62 million, we anticipate that about 11 million of them have mental health and substance abuse issues. Mr. Butterfield. I am encouraged that SAMHSA has helped assist disadvantaged communities through discretionary grants. And as you may know, I represent a rural congressional district in North Carolina where nearly 1 in 4 people are below the poverty level. Can you describe for me some of the programs that SAMHSA has which are effective in addressing mental health in rural and low-income communities? Ms. Hyde. Congressman, rural areas, I think, do have higher levels of--sometimes have higher levels of poverty. They have often less workforce available, so less people to provide those services. We have worked hard with HRSA and their rural program to try to see how we can stretch that workforce, how we can do telemedicine and other kinds of approaches for rural areas and then our Mental Health Block Grants obviously provide to the States dollars that they can use as they see fit. So for States with a higher rural proportion, they certainly could do that. I come from the State of New Mexico. I understand the rural areas out there. And the block grant is an important part of that effort. Mr. Butterfield. Thank you. North Carolina is home to more than 700,000 veterans and has one of the largest veteran populations in the entire country. Seymour Johnson Air Force Base in my district and both the Coast Guard station and the Marines have installations who have supported us. Can you describe some of the crucial programs that SAMHSA supports for returning service members and their families? Ms. Hyde. Thanks for that question. Yes, we have had--in fact, in that Leading Change document we were just talking about earlier, military personnel and veterans is a huge priority for us. We have done everything from Policy Academies, helping States really get their arms around how they can provide services for those individuals. We support and work very closely with the Veterans Administration on suicide prevention efforts and our international lifeline is tied to them electronically. We have incorporated military families and veterans as a priority population within about half of our funding requests. We have really put a major effort there. Mr. Butterfield. And can these programs be affected by sequestration? Ms. Hyde. Absolutely. Mr. Butterfield. It is my understanding that SAMHSA provides support to state mental health agencies on the ground in the wake of natural disasters. In the last year, my district was dramatically impacted by two hurricanes. Most recently, we have seen terrible destruction out in Oklahoma where I was on Tuesday of last week where the total impact won't be known for quite some time. Can you describe the important work that SAMHSA does with the relationship to the storms? Ms. Hyde. Yes. Our disaster preparedness and response efforts have become very well-known. To FEMA, to the Red Cross, and to others we provide a 24/7 disaster distress helpline that is available anytime there is a major disaster like this. It is available all over the country but we target it to the area that is hit. We have all kinds of materials that help people know how to work through disaster issues and prepare psychologically for them. We do training and technical assistance for first responders---- Mr. Butterfield. Let me interrupt you because I am going to have to get this last question in---- Ms. Hyde. Absolutely. Mr. Butterfield [continuing]. And it is important. I think you will agree. It is my understanding that for many insurance companies, preexisting conditions include any conditions which a patient has been treated for in the last 6 months. Under the Affordable Care Act, insurance companies cannot deny coverage due to preexisting illnesses. Our mental illnesses currently considered a preexisting condition by insurance companies? Ms. Hyde. In many insurance companies, they are. Mr. Butterfield. Once the law is implemented, will more individuals with mental health issues and now have access to care under the Act? Ms. Hyde. Yes. Mr. Butterfield. Thank you. Thank you, Mr. Chairman. Mr. Murphy. Thank you. We now recognize the gentlelady from Tennessee, Mrs. Blackburn, for 5 minutes. Mrs. Blackburn. Thank you, Mr. Chairman, and we thank you for being with us today. I want to ask you a little bit about this Alternatives Conference out in Portland, Oregon. You gave the keynote address at the conference in October 2012, is that correct? Ms. Hyde. That is correct. Mrs. Blackburn. OK. Would you mind submitting a copy of your remarks for us? Would that be possible? Ms. Hyde. Congresswoman, I would be happy to. I don't usually have prepared text. I usually do overheads but I will give them to you. Mrs. Blackburn. OK. That would be awesome. And you all sponsored that. I have got a copy of the program; I see you all sponsored this. This is one of your initiatives, correct? Ms. Hyde. It is one of the many conferences and meetings we support, that is correct. Mrs. Blackburn. OK. And I would assume in page 11 of your written testimony you talk about SAMHSA's stewardship, and since you brought up the sequestration a couple of times, my assumption is you are reviewing your sponsorship of such activities. Would that be right? Ms. Hyde. We have been reviewing our sponsorship of all conferences and meetings, and in some cases we are continuing them but with reduced effort. Mrs. Blackburn. OK. Ms. Hyde. In other cases, we are just not doing them at all. Mrs. Blackburn. How much did you spend to sponsor this conference? Ms. Hyde. You know, I don't have that information in front of me---- Mrs. Blackburn. Would you submit that to us? Ms. Hyde [continuing]. But I can get it to you, certainly. Mrs. Blackburn. OK. I think that would be great because if you are looking at a 168 million impact to your budget, then I think that all of these conferences and the programs would be something that we would want to look at very closely. One of the hour-and-a-half long workshops from the October 13, 2012, session is titled ``Unleash the Beast: Primal Movement Workshop.'' It is described in this brochure right here as follows: ``Unleash the Beast is a mind/body fitness program that looks to the animals of the jungle for wisdom and skills that can benefit our lives in a myriad of ways. Through the animal-inspired movements, behaviors, and expressions, participants are encouraged to shed layers of formal conditioning in order to return to their primal nature.'' So is it true that SAMHSA provided funding for this? Ms. Hyde. As I indicated, we provide funding for the conference. That is correct. Mrs. Blackburn. OK. Are you able to provide us--did you attend this workshop? Ms. Hyde. No, ma'am. Mrs. Blackburn. You did not? OK. Can you give me any idea of specific examples of such animal-inspired movements, behaviors, and expressions and discuss what studies where evidence has shown them to be effective in treating mental illness and humans? Ms. Hyde. As I said, I didn't go to that conference or that particular workshop. I can tell you that things like meditation, yoga, other kinds of movement is appropriate for-- -- Mrs. Blackburn. So that is animal movement? Ms. Hyde [continuing]. Developing stress--for releasing and developing and---- Mrs. Blackburn. That would be animal--let me move on. Ms. Hyde [continuing]. To manage stress. Mrs. Blackburn. When did you begin sponsoring the Alternatives Conference? Ms. Hyde. I don't remember the first year. We can find out for you. Mrs. Blackburn. OK. We would like to know that and I think, you know, one of your exhibitors here, Mind Freedom International is one of the groups that had a table there. They encourage people to come off their meds, and I think we would be concerned about that. I also want to know how much money you have spent since the inception of this Alternatives Conference and in conferences in general? Let us help you with this budget gap that you have, and this may be a way to find out. Would you please submit that to us? Ms. Hyde. I am sorry. Can you clarify what you would like to see? Mrs. Blackburn. Money, how much have you spent on the Alternatives Conference and how much do you spend on conferences in total? And do you pay speakers' fees and travel? Is that covered out of what you are paying? Ms. Hyde. Congresswoman, it depends on the conference what we pay for. We have reduced our conference support significantly---- Mrs. Blackburn. OK. What about scholarships to the conference? Does SAMHSA cover scholarships to the Alternatives Conference? Ms. Hyde. We do sometimes provide---- Mrs. Blackburn. OK. Could you submit that amount to us? Ms. Hyde [continuing]. Scholarships to this and to other conferences. Mrs. Blackburn. OK. And I would assume they are going to the Unleash the Beast Primal Movement Workshop on taxpayer funds. March/April 2011 SAMHSA newsletter highlighted the Agency's use of art to raise awareness around behavioral health. Specifically, an award-winning artist, Sam English, was commissioned for $22,500 to create a painting because of his familiarity with prevention and recovery populations. What value--I want you to tell--what value do the American people obtain from SAMHSA's funding of a piece of artwork such as this? Ms. Hyde. We have a responsibility, Congresswoman, to get the word out about behavioral health to all kinds of populations. In this case, the tribal populations are very clear that the way to do that is to use people from their tribes and nations. This was a tribal---- Mrs. Blackburn. $22,500 for a piece of art? Ms. Hyde. That number is not correct, but this tribal leader is actually a person in recovery and has produced documents and opportunities in the past for other substance abuse programs. Mrs. Blackburn. Please submit the correct number. And I yield back my time. Mr. Murphy. Thank you. The gentlelady's time expired. I now go to the gentlelady from California, Ms. Castor, for 5 minutes. Ms. Castor. Thank you, Mr. Chairman. I would like to focus your attention on mental health care for children and teens, particularly in schools because what I have heard from so many of my school districts at home and the teachers and parents there is that the schools are a terrific place to identify the emerging issues for the child's mental health or it is the teacher on the front line that understands very well the emotional health of that child day in and day out and that, you know, many schools are able to maybe have a guidance counselor or a school psychologist, maybe just part- time, and they get identified. But there seems to be a real lack of resources available for the true treatment and counseling that that student needs. So many of the parents I hear from, they don't have health insurance or they have a policy that does not provide it. That is going to get better under Mental Health Parity and the Affordable Care Act. But I still think that what I am hearing from back home is the schools would have the capacity to do more with having psychiatrists and some counselors available. In your testimony--and I understand SAMHSA has some oversight or has oversight of the Safe Schools and Healthy Students Initiative and also Children's Mental Health Initiative. What I have heard from folks back home is while they value those dollars, it is just a drop in the bucket and that resources that were available in the past just aren't there anymore. Could you speak to that and give us a summary of the Safe Schools and Healthy Students Initiative and Children's Mental Health Initiative? Ms. Hyde. That is correct. The Safe Schools, Healthy Students is a very effective program that we have worked with the Department of Education and the Department of Justice on over the years. It brings together communities, parents, schools, and others to make sure that young people are safe. The program has resulted in great outcomes. We have seen less violence, more perception of safety, more referrals by about 500 percent, more referrals to behavioral health treatment, so as people are able to identify young people in need. So it is a very effective program. The President has proposed to build on that program in the fiscal year 2014 budget by Project Aware, which would not only expand Safe Schools, Healthy Students statewide in some States, but also add a mental health first aid to help teachers and parents, first responders, and others identified mental health issues early. Ms. Castor. But what is your feeling on or what is your understanding about the needs? As I mentioned earlier in my opening statement, the needs are far outstripping the resources that are available at the local level, state level, and federal level? Or is it a fact that policymakers simply haven't made mental health services a priority and haven't provided the investment that is necessary? Ms. Hyde. That is absolutely correct. There is not enough. I started out in my testimony, as you may remember, with saying that only about 6 percent of health care spending is mental health, and that is far below what the need is. The President has proposed additional dollars to do additional workforce and has also proposed additional dollars to try to implement the efforts that we have. We also know that the Affordable Care Act will add a lot more coverage for this, but the workforce needs to grow to meet that need. Ms. Castor. How do you collaborate with the Department of Education? Outside of Safe Schools, Healthy Students, what is your understanding of what the Department of Education is able to provide when it comes to mental health care to our schools? Ms. Hyde. They actually provide a lot of in-school programs, so they support, as does HRSA and other school-based health clinics and others. We provide assistance in the community with the referrals and the connections in the community-based programs. We work with them to provide the materials when they need it for evidence-based practices, and we work to provide training for teachers and others---- Ms. Castor. Does that include the IDEA, Individuals with Disabilities Education Act? Ms. Hyde. In some cases, yes, but we are focusing on not just individuals with identified needs but individuals who haven't yet been identified. We also provide in-school training for teachers to try to help manage behaviors in the classroom. Ms. Castor. Do you really believe when you look at the needs all across America when it comes to mental health for our young people that we are even with all of these initiatives we are really being effective? I mean how do we increase capacity to serve children and need to really be effective and integrated in the school-based setting? Ms. Hyde. Well, I think we need more programs like Safe Schools, Healthy Students, and more like Project Aware that the President is proposing. The fact is we just have a significant under-commitment to mental health and mental illness treatment and recovery in our country and we need more of that. The Affordable Care Act will help with that but only as we continue to build up the workforce to be able to meet those needs. Ms. Castor. Thank you very much. Mr. Murphy. Thank you. I now recognize Mr. Olson from Texas for 5 minutes. Mr. Olson. I thank the chair and thank him for holding this very important hearing. America's mental health problems that lead to violence may lose control every day in America. The violence doesn't just happen at Virginia Tech; it doesn't happen in a parking lot in the Safeway in Tucson, Arizona; it doesn't just happen in a movie theater in Aurora, Colorado, or at a school in Newtown, Connecticut. They happen 1.5 miles from my hometown, my home, my hometown of Sugarland, Texas. At about 9:00 p.m. on Sunday, April 7, of this year, a 31- year-old constituent hit the wall. He had been sick for about 13 years and was in the process of moving back home with his parents. He had been seeking painkillers from doctors but his doctors did not give him the drugs. He became angry with his parents and threatened them with a hatchet and a rock. Terrified, they fled their own home and called 911. The Sugarland police showed up. The son was barricaded in his parents' house. Eventually, he emerged with a rifle, and when he pointed it at the Sugarland police, he was shot and killed in his front yard. His parents heard the gunshots that killed their son. And we can never accept what happened in my hometown of Sugarland, Texas. Administrator Hyde, I know that SAMHSA is a small agency. You have an important role to play. You mentioned earlier this year in your testimony before the House Appropriations Committee on children's mental health on March 20 that the President has directed his Secretaries of Health and Human Services and Education to foster a national dialogue on mental health. What if it all is SAMHSA's role in this dialogue being coordinated with the $130 million in new SAMHSA-led programs that the President announced on January 16 of 2013? Basically, how is that money being used in this new initiative? Ms. Hyde. Congressman, that money that is being proposed is for fiscal year 2014 so we don't have those funding--that funding yet. It would require Congress to act for us to have it. The description of the incident that you described is a huge tragedy. These are not things that we want to happen. We have models out there of mental health and crisis intervention working with police and we have been working a lot with police and sheriffs association. We don't have a program specifically around crisis intervention. I wish we did. It is something we know that we can do better about but we don't have the funding to do. States use some of their block grant funds for these dollars but they don't stretch nearly far enough. So this is an area where we have some evidence-based practice and we don't have the resources to put it into place all over the country as we should. Mr. Olson. Thank you, ma'am. I will have some questions for the record but I yield the balance of my time to my colleague from Texas, Mr. Burgess. Mr. Burgess. I thank the gentleman from Texas for yielding. I just had a follow-up question on what Mr. Butterfield was pursuing on to the effects of the sequester. I mean we hear a lot about that in this committee and I just have to tell you I am struck by the fact that it seems that nowhere in the federal agencies is anyone responsible for the prudent management of taxpayer money. In private business when you are struck with a budget reduction, which happens and certainly happened to me when I ran my practice, the first thing I did was not sacrifice customer service or sacrifice activities that were central to the core mission of my business. And yet, we hear it time and time and time again from the CDC, from HHS, now from your agency that because of the sequester you can't perform the functions of your core mission, and yet there are ancillary activities that are occurring that consume large amounts of dollars. I mean it is basic Six Sigma management. You do your core mission first and everything else is secondary to that. And, you know, we hear stories over and over again about incompetence of the federal agencies. I would just urge you to be certain that your number one mission needs to be fulfilled and everything else comes secondary. I thank the gentleman for yielding and I will yield back. Mr. Murphy. I now recognize Mr. Green for 5 minutes. Mr. Green. Thank you, Mr. Chairman. Administrator, welcome. I guess because you have a lot of Texans on the committee, you got my neighbor and Dr. Burgess of North Texas. I have a district in Houston, and previously, my colleague Ranking Member DeGette touched on a criticism from our second panel on your agency, and I would like to pursue that a little bit more. Dr. Torrey claims that incarceration of mentally ill people in jails in your presence is not a priority for SAMHSA. One, is this true? And are incarcerated mentally ill people not your priority? What agency do you work with that addresses the concern of this particular population? Ms. Hyde. Thank you for the question. We do have criminal justice programs in our budget. We do a lot of work with Sheriffs Associations, with jail and corrections practitioners. We have done a significant amount of work with juvenile justice and interfaced with the Department of Justice on that. The dollars appropriated for these activities are fairly small compared to some of the other dollars we have, but to the limits of our Appropriations, we have done a lot of work in the criminal justice area both with substance abuse and mental health. Mr. Green. I appreciate it. And, well, if you could get me anything that you have worked on in Texas so I could see it. In an earlier life I did mental health as an attorney representing folks and I have worked with our sheriff. I watched last year as they were trying to divert people in Houston Harris County from, you know, being incarcerated and literally walk them two blocks to a federally qualified health clinic that also sets up an appointment, get them on their meds, looks for housing, and things like that. So we don't provide most of that funding. It comes locally, I guess, but it would be good if we could just provide resources to particularly in urban areas but I know rural areas have the same problem. Dr. Satel, another panelist, alleges that SAMHSA's guiding philosophy of care is the recovery model and its tears policy away from the needs of those living with serious mental illnesses. Administrator, can you describe the recovery model and your views on whether it is an adequate guiding principle for the Agency? Ms. Hyde. Thank you, Congressman. The recovery is important. It is part of what we are about. We do want people to recover. I think there is an assumption that recovery means not getting treatment. That is not true. Recovery includes getting the kind of treatment and services a person needs to maintain their symptoms as well as their lives. We separate recovery into four areas: the treatment or health area; as well as housing to make sure that people don't end up homeless; and to make sure that they have the social networks they need to survive in the community; and then that they have the jobs or the education that they need to make a living. So we support all of those in the recovery effort Mr. Green. Well, and I understand recovery is important but, you know, I consider mental illness something you manage, too. And, you know, sometimes I am not going to recover from a heart condition. I may manage my illness and I would hope that is part of your recovery method, being able to manage that illness because that was our problem of getting people to realize their illness and you can manage it and function to sometimes a higher level instead of being able to recover from your particular mental illness issue. One of the issues that came up and Dr. Burgess touched on it that Dr. Torrey claims your agency spent 22,000 on commissioning artwork to hang in your offices, and I hope that was before sequester and it was something you couldn't get out of, but that is what Members of Congress and O&I Committees are looking at. And can you explain that expenditure? Ms. Hyde. You know, Dr. Torrey and I have known each other for a long, long time. He claims many things, not always that I agree with. We have an obligation to try to do public awareness and support. One of the things that we did is some special approach to try to get information out to tribal communities. We used a person in recovery from substance abuse and mental illness who has provided other efforts and other art for posters which we produced. We produce posters for a lot of places in a lot of ways, and the combination of those efforts was what you are referring to. The dollar amount is not correct but we will be glad, as requested, to provide that to you later. Mr. Green. OK. Mr. Chairman, thank you. Ms. DeGette. Would the gentleman yield? Mr. Green. I would be glad to yield my last 2 seconds. Ms. DeGette. And when did the Agency purchase that artwork? Ms. Hyde. It was a couple of years ago. Ms. DeGette. So it was before sequester took place? Ms. Hyde. Absolutely, yes. Ms. DeGette. And I am going to back up what Mr. Green was saying and say I am hoping that those kinds of expenditures aren't being made right now with sequester and other cuts looming. Ms. Hyde. I think it is fair to say that we have had to cut a lot of our public awareness efforts, yes. Ms. DeGette. Including things like that? Ms. Hyde. Including things like that. Ms. DeGette. Thank you. Thank you. I yield back. Mr. Murphy. Thank you. The gentleman's time has expired. I now recognize the gentleman from Virginia, Mr. Griffith, for 5 minutes. Mr. Griffith. Thank you, Mr. Chairman. Thank you for being here today. Appreciate it. There is substantial evidence that court-ordered assisted outpatient treatment can reduce hospitalization and length of stay, increasing the receipt of psychotropic medications in intensive case management services, among other improved policy-relevant outcomes. Does SAMHSA provide financial support to organizations that oppose efforts to expand court-ordered outpatient treatment programs nationwide? Ms. Hyde. Again, we provide resources to organizations that may have positions that are not consistent or that we don't necessarily espouse one way or another. So I can't really answer that question. My guess is that there are probably some of the organizations that receive some dollars and don't appreciate that approach. Mr. Griffith. Because there appears to be some data that some SAMHSA-supported statewide programs such as the Pennsylvania Mental Health Consumers Association and the California Network of Mental Health Clinics actively lobby against proposed expansion of assisted outpatient treatment in their home States. And I have to wonder while supporting prominent skeptics of assisted outpatient treatment, have you all launched or do you have any plans to launch an assisted outpatient pilot program to maybe encourage folks to be in favor of these types of programs? Ms. Hyde. I am sorry. Let me comment first that no one using our dollars has the right to use federal dollars for lobbying. So to the extent there is an organization that we find that is doing something of that nature, they should be either using other dollars or not doing it. So---- Mr. Griffith. Yes, ma'am. Ms. Hyde [continuing]. We don't support that. On the assisted outpatient treatment, the research that has been shown for assisted outpatient treatment to be effective also is very clear that it is the treatment and service that is effective. So to the extent that, for example, in New York where there was a major assisted outpatient treatment program and an evaluation of that program that was extensive, there were also a lot of new dollars poured into that system to make it work. So to the extent that the services are there, then assisted outpatient treatment may be effective for some individuals. Mr. Griffith. And you certainly don't oppose in those cases where it is necessary involuntary treatment? Ms. Hyde. We do not oppose any kind of treatment that is effective, absolutely not. Mr. Griffith. OK. And you don't have any problem with having those folks then put on a list to not be able to purchase firearms? Ms. Hyde. I don't have an objection to that. I do have objection to some of the language that is in the law about that, but I think everybody is working on that. We are looking at it, things like mental defective and things of that nature don't make a lot of sense today, so we do need to revise that law in some ways. Mr. Griffith. Well, we certainly need to make sure that those who have severe mental illnesses with a tendency or either the individual has a history or the diagnostic area, that those folks are put on a list so that they can't purchase firearms lawfully. Wouldn't you agree with that? Ms. Hyde. I think our department is working with the Department of Justice on the language around that law, yes. Mr. Griffith. All right. And if I can be of any assistance on that, please don't hesitate to contact me because we have serious concern. I represent the 9th District of Virginia and the Virginia law had to be changed when I was in the state legislature because we let Mr. Cho slip through the cracks. And he had been told by a court to go get help but nobody ever made sure he got that help. And we had to make sure that we changed the law because not only did he not get the help but that he was never placed on the list of folks who weren't able to buy guns. And so after he was court-ordered to get the help, he went out and purchased firearms and he wasn't on anybody's list as a no. So we had to change that law. I would be happy to help in any way that we can on that. And in regard to the folks that were doing some lobbying, I know they are not supposed to and certainly not supposed to use SAMHSA funds for that, but I have read some reports that indicate that might be happening, and one of the suggestions is that Congress could consider giving you all more authority to regulate those individuals and to regulate patient advocates both on lobbying and other issues. Would you welcome that additional responsibility? Ms. Hyde. Mr. Congressman, if you have any information that suggests someone is using our dollars to lobby, please let us know. We will take a look and we will exercise whatever authority you give us to do the right thing. Mr. Griffith. All right. I appreciate that as well. These are very serious issues. I do note that when you were talking about funding, maybe we need to do something because I noticed in your written report that you are doing some kind of a study that indicates folks are using less tobacco, particularly in your youth programs. And while I certainly don't advocate that young people be involved in the use of tobacco and recognize that that is a substance, when we are dealing with serious mental illness versus tobacco use, I would rather put the money on serious mental illness. Do we need to put that into the language of your appropriations or is that something that you have the power to do? Ms. Hyde. Well, once again, 70 percent, give or take, of our dollars are about substance abuse, and tobacco use, especially among young people, is a substance of abuse and addiction does cause health issues. About half the deaths---- Mr. Griffith. Can you give me the dollar amounts that you all use on your tobacco programs? Ms. Hyde. On tobacco? Sure. Mr. Griffith. I would appreciate that. And with that, Mr. Chairman, I see that my time is up and I yield back. Mr. Murphy. Thank you. The gentleman from Missouri is now recognized, Mr. Long, for 5 minutes. Mr. Long. Thank you, Mr. Chairman. Thank you, Mr. Chairman. And in full disclosure, Ms. Hyde, I think it is important that we state for the record that you and I both lived in Springfield, Missouri, for a while. Is that correct? Ms. Hyde. That is correct. I grew up there. Mr. Long. So did I so welcome to the Committee. Glad to have you here. You mentioned earlier that sequestration had cost SAMHSA I believe $168 million out of the budget? Ms. Hyde. That is correct. Mr. Long. And that is a budget of what size? Ms. Hyde. It is about $3.2 million, 3.3. It depends on the year. It depends on where--before or after sequester. It is about $3.4 million, all sources. Mr. Long. OK. Growing up in Springfield, Missouri, you are familiar with---- Ms. Hyde. I am sorry. I am sorry. Excuse me, 4 billion. It is about $4 billion. Mr. Long. Four billion for SAMHSA? Ms. Hyde. About $3.4 billion altogether, but remember about 70 percent of that is substance abuse. Mr. Long. Is what? Ms. Hyde. Is for substance abuse. Mr. Long. Substance abuse. There is been a lot of talk about sequestration today and you are familiar with Springfield, Missouri, growing up there as I did. And at the corner of Glenstone and Battlefield, the Barnes & Noble there you could find myself and my wife and our daughters in there about 3 nights a week. And I read a lot. And especially in this occupation we fly out here on Monday and fly home on Friday, you read a lot. And I am kind of old-fashioned. I don't read the I whatever Kindles and I-books and things like that. I like the pages in my hand and all of that. I don't know why but I just like that. And so one book that I bought was Bob Woodward of Watergate fame. He wrote a book last year. It came out September 11, same day that our consulate was attacked in Benghazi. But anyway, I can get a picture of it on my iPad. I can't read it on my iPad that I can get a picture of the book, ``The Price of Politics.'' And that is pretty good for me, wasn't it? So I probably bought it on September 12, because I was anxious to get the book because it was kind of my first 2 years up here and what went on in Congress and all of the budget battles we had where we spent 42 percent more than we take in every day in this town. And no one, as you know in Springfield, Missouri, where you grew up, where I grew up, you can spend 42 percent more than they take in. So the book I was anxious because I knew it was going to walk us through the process and when Speaker Boehner would talk to the President and Eric Cantor would be involved in back-and- forth and everything. So I got a hold of the book, read it, and then I happened to run into--I was watching Morning Joe one morning and then I saw Bob Woodward on there being interviewed about a different topic, and then, as fate would have it, I am walking across the Hill here and get to a stop sign on a corner and there stands Bob Woodward, still has his makeup on from Morning Joe. And I went up to Mr. Woodward and I said, Mr. Woodward, I have got to tell you. I said I just read your book ``The Price of Politics'' and loved it. I said I am going to say something to you--and this is like in November/December last year--and I said I don't know about the meetings that I wasn't in, but the meetings that I was in I said it was like you had a tape recorder in the room. That is how accurate your reporting was. He said, well, thank you. Thank you very much. And in that book where we can only assume, I think, that if the reporting was accurate in the meetings I was in that you would be safe to assume that the reporting was accurate in the meetings I was not in. And I believe--I am not sure but I think it is on page 326 but I don't know how to read a book on my iPad--but I think it is on page 326 talks about where sequestration came from. Do you know where it came from, whose idea it was? Ms. Hyde. Congressman, I think these are issues that are going on between you and the White House and others and I think that you should take those questions and comments to them. Mr. Long. Well, I think that you have used sequestration of a lot here today and 168 million out of your budget, and, you know, according to Mr. Woodward who was accurate in the meetings that I was in, it came from the White House. It came from the President, sequestration. And now that it has gone into effect, we have a lot of different agencies coming to us on a lot of different issues and so I just want to point out for the record where sequestration came from so that when we are talking about it in hearings like this, and we may talk about it later in the second panel today, I just thought that was important to bring out. And I yield back. Ms. Hyde. Yes, Mr. Congressman, I think sequestration came from a number of different drivers and I think it is very clear that Congress had the authority to make a decision that it would not go into effect. I think everybody wanted it not to go into effect. I think everybody assumed to that there would be another---- Mr. Long. Isn't that kind of--well, I am not going to get into a discussion with you and I am controlling the time, but I think it is kind of bad to come up with a law that you are going to pass thinking it won't go into. And I yield my time back to the chairman. Mr. Murphy. The gentleman yields back. His time is expired. And I now recognize the gentleman from Georgia, Dr. Gingrey, for 5 minutes. Mr. Gingrey. Mr. Chairman, thank you very much. Administrator Hyde, can you understand the criticism leveled by some against SAMHSA that the Agency's focus on behavioral health being such a broad and amorphous category has come at the expense of prioritizing resources for treating those with serious mental illness? Ms. Hyde. No, I don't agree with that. And again, behavioral health is a broad term that we use for both substance abuse and mental health and mental illness. It is about prevention, treatment, and recovery. So it is a broad term. Our budget is about 70 percent substance abuse. The other part of our budget is about 75 to 80 percent about serious mental illness and serious emotional disturbance. So no, I don't understand the criticism. Mr. Gingrey. Well, in other words, look, to me it has drawn attention away from the biological basis behind the most serious of these illnesses focusing instead on environmentally driven behaviors. One example of this is something called Leading Change, SAMHSA's plan of action for 2011 through 2014. In this document of over 100 pages setting out the Agency's eight core strategic initiatives for the coming years, the word of schizophrenia or bipolar disorder do not appear at all. Are these conditions not defined by both the National Institute of Mental Health and SAMHSA as examples of SMI, serious mental illnesses? Ms. Hyde. As I said earlier, the Leading Change document doesn't have any diagnoses in it. It is not the purpose of that document. The definition of serious mental illness is different in different places. Congress has given us a definition in one place that is different with the NIMH in another place. We have--each State makes their own definition of it for purposes of the block grant, so there is lots of different definitions, and certainly, people with schizophrenia and people with bipolar disorder are some of the diagnostic categories that could be a person with serious mental illness. In many cases, it also includes a function or a history that makes the individual in need of intensive treatment. Mr. Gingrey. Well, there is a lot of controversy. I read an article this weekend in the Wall Street Journal that expanded there was a lot of coverage of mental illness. Those of you may be here on the panel or members of the subcommittee may have read these articles about DSM-V and the concern, you know, about how in the world, you know, psychiatrists and psychologists getting away from really the cause of some of these serious things and just throwing medication at it. Maybe that is another subject, maybe not. But according to the National Institute of Health, schizophrenia affects around 2.5 million Americans while bipolar disorder affects 5.7 million Americans in this country. And I am discouraged that it seems to me, Madam Administrator, it just seems to me that your action plan fails to address both of these populations of people. In the time remaining, can you please explain to this committee what if anything SAMHSA has done in the last 5 years which has impacted treatment for a patient with one of these diseases if they walk into a typical community mental health center in an average State, Georgia, mine; what is it, Missouri? Yours and my friend Mr. Long in front of me. What happens if a person walks into these community mental health centers in the average State in this country, Missouri or Georgia? Ms. Hyde. We know health centers across the country frequently are funded by the Mental Health Block Grant, which SAMHSA administers. They frequently are recipients of SAMHSA grants. Almost all of them now get Medicaid dollars and Medicare dollars. Most of them now get private insurance dollars as well. So as we indicated earlier, \2/3\ of the money to fund those services come from Medicaid, Medicare, and private insurance. The SAMHSA grant that we provide help those community mental health centers to provide those things that a typical insurance benefit would not necessarily provide. We provide it for both a different kind of set of services, evidence-based practices that are over and above those, and we also provide it for those individuals who were not covered the moment. So there is a lot of ways in which if you walk into a community mental health center, you can bet they are touched by SAMHSA funding and they certainly may very well be touched as well by SAMHSA technical assistance, by their training, by our public education and outreach and awareness. They may use our data. There is a number of ways in which those community health centers are touched by us. Mr. Gingrey. Madam Administrator, that is helpful. Thank you and I yield back. Mr. Murphy. Thank you. I now recognize the gentleman from Iowa, Mr. Braley, for 5 minutes. Mr. Braley. I want to talk about the Garrett Lee Smith Suicide Prevention Program, a program that is very personal to me because I lost my niece to suicide her senior year of high school, and I am concerned about the proliferation of social media sites and the amount of information available to teenagers who are contemplating suicide and who have some of their concerns reinforced about information provided by those sites. What are we doing to monitor the traffic on Facebook and Twitter and other social media sites to be more aggressive in intervening with young people to prevent them from taking this most drastic step to end their problems? Ms. Hyde. It is a great question. We have a relationship with Google, who actually has allowed us to have our National Suicide Prevention Hotline be the first thing that comes up. You know, normally, Google will just do a--it will come up different every time, but if you Google suicide, it will come up our lifeline number first. We also have relationships with Facebook who worked with us over the release last year of the National Strategy for Suicide Prevention, which was the Surgeon General's report that was developed by a public-private partnership that we participated heavily in. Facebook is one of the partners there and they have actually--now are monitoring some of the language and some of the materials or some of the chatter that is going on and trying then to intervene and allow that individual to know that there is a way that can reach out. So we have good public- private partnerships working with entities like that to try to address some of the issues you have raised. Mr. Braley. What are we doing to affirmatively promote information through those platforms to try to counter some of the misinformation and encouragement that takes place over those platforms and educate young people to the alternatives that are available to seek help when they are in such a time of crisis in their lives? Ms. Hyde. Again, I think there is a couple of ways. We have a Garrett Lee Smith, as you know, program that is campus-based. That is one of the age groups that has a high proportion of death by suicide and a high proportion of individuals who either seriously consider or act on those issues. Those grants help to raise awareness. They help to provide support groups. They help to provide actually information to faculty and students. So we have a fairly extensive--again, limited by the dollars that we have, we have a fairly extensive effort around that. We also do a significant amount of public awareness and support with materials, posters, things to hand out to people. I have got them in my backpack. I carry them around, signs of suicide prevention that you can give to anyone who appears to be talking about that kind of thing. We have also tried to provide some training for parents and survivors of actual attempts as well as parents of--or family members of those who have experienced this. So we do a fair amount of work in that and we do it with partners. It is not just SAMHSA. It is some of our stakeholder partners who work on this issue extensively. Mr. Braley. Thank you. That is all I have. Mr. Griffith [presiding]. I now recognize the gentlelady from North Carolina, Mrs. Ellmers. Mrs. Ellmers. Sorry. Thank you, Mr. Chairman. Thank you, Ms. Hyde, for being with us today. You know, mental health in this country is so important and certainly one of the issues that Oversight and Investigation is taking on with a great passion. We know that the health care system in this country needs to be reformed. We know that the mental health system in this country needs to be improved upon. And that brings me to my concerns about the way that your organization is moving forward with hard-earned taxpayer dollars. I am concerned that there seems to be a lack of physicians and nurses and social workers that are a part of your organization, and I have reviewed all of the information here, and I would like to hit on a couple of very specific issues, especially with healthcare professionals. I read the brochure on the Alternatives Conference that you are a part of, and I don't see anywhere where they discuss continuing education credits for psychiatrists, for psychologists, for nurses, for social workers. Is this correct? I mean is there no program that you are associated with with at least education and training for these healthcare professionals? Ms. Hyde. No, that is not correct. Alternatives is just one thing that we do. We also work with--I gave a keynote at the American psychiatric nurses Association as well. So there is lots of different efforts that we do with psychology groups, social work groups, nursing groups and others to try to---- Mrs. Ellmers. But not for this particular conference that you do like, again, providing accredited hours of education training for these individuals? Ms. Hyde. Not at--I don't believe that is---- Mrs. Ellmers. Through federal dollars? Ms. Hyde. I would have to check that for you. Mrs. Ellmers. OK. And if you could provide to our committee those keynote points that you made at that particular conference, that would be helpful as well. Also, some of the other issues, and there again we are looking at federal dollars that are being spent here. We discussed the sequester cuts that you have identified as problematic, and I can certainly understand that as well. However, I think there are dollars that are being spent here that aren't necessarily getting to the root of the mental health issues that we are faced with in this country, especially with young people. But also in the document that you have, Leading Change, you do make very specific reference to suicide, substance abuse, which obviously definitely falls under your jurisdiction, depression, PTSD, so you are able to name specific diagnoses. So this is something that you do not have any difficulty talking about specific diagnoses, is that correct? Ms. Hyde. In the right context, absolutely not. We don't have any problem with that in the---- Mrs. Ellmers. OK. So that is a yes. In your document Leading Change again, you do not specifically mention schizophrenia, bipolar disorder. So is that something that you do not regard as serious mental illness? Ms. Hyde. Of course we consider those serious mental illness diagnoses. That document was not a clinically-based document. It laid out our eight strategic initiatives ranging from prevention to military families to trauma issues to quality issues to public awareness and support and to electronic health records. Mrs. Ellmers. OK, well---- Ms. Hyde. The nature of that document---- Mrs. Ellmers [continuing]. I would like to hit on one specific area, though, in relation to those with my 1 minute that I have left. One of the areas there again getting back to that document, getting back to schizophrenia and bipolar, do you believe medication is a proven evidence-based treatment for these diagnoses? Ms. Hyde. Absolutely. For most people. There are, however, a number of people who have those diagnoses for which medication is still not effective. Mrs. Ellmers. Well, see, that is one of those curious areas there because you also are providing funding to organizations that support and promote taking away medical treatment. Do you acknowledge that? Ms. Hyde. We provide funding for entities to do the grants that we give them to do. Whether or not they espouse other---- Mrs. Ellmers. Well, then, what are the criteria that you would give a grant if it isn't a treatment that you would support for mental illness---- Ms. Hyde. The---- Mrs. Ellmers. Ten seconds. Ms. Hyde. It depends on what the grant is. There is a lot of different grants that we give for a lot of different purposes. I would be glad to talk to you offline about that some more. Mrs. Ellmers. Well, I would like to see that criteria of how you qualify an organization that you are giving hard-earned taxpayer dollars when it is something as serious as mental health. And if you could provide the criteria or the application process that would be wonderful so that we can see who gets this money and how you qualify them. Thank you very much. I went over and I apologize, Mr. Chairman. Mr. Griffith. I now recognize the gentleman from California, Mr. Waxman, for 5 minutes. Mr. Waxman. Thank you, Mr. Chairman. I understand there has been a good deal of discussion regarding the role of Protection and Advocacy Program, and I am very familiar with this program having worked on the authorizing statute when I was chairman of the Health and Environment Subcommittee. The Protection and Advocacy for Individuals with Mental Illness Act authorized Protection and Advocacy organizations to, one, protect and advocate for the rights of people with mental illness; and two, investigate reports of abuse and neglect in facilities that provide care or treat people with mental illness. I know we have heard criticisms about efforts of these entities in specific cases, but I want to underscore two points: First, Protection and Advocacy organizations are designed by their respective States and are acting within the scope of congressionally mandated activities; and second, absent their efforts, thousands of individuals would continue to experience abuse, neglect, and violation of their civil rights. For example, in 2011 the PAIMI program supported casework for approximately 4,000 children and adolescents, nearly 13,000 adults and elderly individuals, and entities receiving funding resolved over 11,000 complaints. Now, Administrator Hyde, you also noted that SAMHSA is developing a framework to guide behavioral health services and programs throughout the country and to provide a consistent set of measures for use by various stakeholders. Can you tell us how you expect this framework to improve accountability for your stakeholders? Ms. Hyde. Thank you. Yes, we are developing a National Behavioral Health Quality Framework. It is modeled on the National Quality Strategy that was required by Congress so we have been working with the organizations to develop that. It has six goals, things like safe care, evidence-based care, effective care, patient-centered care, et cetera. And we are developing rules and measures with the National Quality Forum and others to populate what that quality framework might look like. Mr. Waxman. Is there anything else you would like to add with regard to SAMHSA's ongoing accountability efforts? Ms. Hyde. Yes, thanks for the question. We--every one of our programs--our grant programs we evaluate. We have evaluation data. We have one of the highest number of the GPRA, what we call GPRA or government accountability measures of any of the agencies. We report that data. We make it available. All of our grantees are doing that. We also work hard--we are in the process of revising our data reporting and data collection activities both for our discretionary grants, as well as for our block grants to assure that we have the best data possible available for you all, as well as for the public. So we do a lot of work in this area. We also do oversight of each of our grants and then we respond to complaints and investigations and investigate those when they are brought to our attention. Mr. Waxman. And even as you are requesting more information from your grantees, I understand there are instances in which you lack the authority to require States and other grantees to report on certain measures, for example, within the Community Mental Health Services Block Grant. Is that correct? Ms. Hyde. Well, the block grant is meant to be a flexible funding stream, so for States--they make different choices about that. They do provide us information about how they use those dollars and we do report those back. We also--but we--so we have limited authority in some ways but I think it was designed to be a flexible funding stream for each State. Mr. Waxman. Well, it is a flexible funding stream for each State but when you try to get information from them and you are asking them to report on certain measures, are you able to get the information you need? Ms. Hyde. To an extent we are and we have just begun a new effort with the States to try to see how we can collectively report data better. We all want to improve that so we have data now. We have information about what the States use the dollars for---- Mr. Waxman. Yes. Ms. Hyde [continuing]. But we do want to improve those data. We are always looking for ways to improve that accountability for Congress and the public. Mr. Waxman. I think we can agree that it is important to make sure there are clear reporting requirements and consistent measures in place so that we can track progress over time. I hope that we can work together to support SAMHSA's efforts on this issue. And I thank the chair for recognizing me. I yield back the balance of my time. Mr. Murphy. I thank the gentleman. I now recognize the gentleman from Ohio, Mr. Johnson, for 5 minutes. Mr. Johnson. Thank you, Mr. Chairman. And I appreciate the opportunity. Thank you, Ms. Hyde, for being here today. I do have one comment I want to make, though, before I get into the questions because I was struck by what my colleague from Missouri mentioned about the idea of sequestration because that seems to be a hot topic today. We consistently have administration officials come before our committees to talk about sequestration and the fact that it is hurting their ability to do the job that they are assigned to do. However, we know and it has even been admitted that the idea of sequestration came from the White House. I came from the floor just a little bit earlier where our minority whip talked about or tried to make the case that once again this was a Republican House idea, which it was not, and that we have abdicated our leadership because we haven't worked across the aisle to try and replace the sequestration when in fact we passed two pieces of legislation in the last Congress that would replace sequestration, give the Administration the flexibility that it needed by making more responsible spending cuts. So I am a little frustrated with the disingenuousness that continues to come from the Administration and the agencies that try to blame sequestration on their inability to do their jobs. I wonder where that backlash was when the Administration was putting forth this idea. That is just a comment. Let me ask you, Ms. Hyde, how our review criteria for SAMHSA's formula and competitive grant programs developed? Ms. Hyde. Review criteria come from the RFAs, which is request for applications. So when we developed the RFAs based on congressional input and the program design, then we develop criteria from that about what the applicants have to meet. There is a checklist that the reviewers have to go through. They actually have to put the page number of the application of where the different criteria are in the application. They are scored and then that scoring drives the decisions about development. Now, that is sort of the discretionary grants. The formula grants like block grant and the PME program and others, those are done by application from the States because each State is entitled to those dollars so long as their application---- Mr. Johnson. How do you ensure that SAMHSA grant reviewers follow the criteria consistently? Ms. Hyde. As I said, there is a checklist and they have to identify the page number in the application where they actually saw the criteria that they are looking for in the grant review. So there is an extensive documentation about how they reviewed the criteria and how they--the scoring occurs. Mr. Johnson. What kind of oversight does SAMHSA perform over its grantees after the grant is awarded? Ms. Hyde. Each grantee has a grant project officer. Those grant project officers provide oversight by visits, by audits of papers, by technical assistance, and by looking at the materials that are provided for reporting and overseeing whether or not those are up to snuff and what they are required for meeting their grant performance. Mr. Johnson. How often is this type of oversight performed? Ms. Hyde. It depends on the situation and depends on how many grantees there are, what kind they are, whether or not they are sort of usual grants or new grants. So new grantees may get additional attention or more oversight than grantees who have been going for a while, et cetera. Mr. Johnson. OK. Ms. Hyde, some have called the annual Alternatives Conference that is funded by SAMHSA to be the largest anti-psychiatry, anti-treatment meeting in the U.S. In your view, what is the value that has been obtained for the American people and more specifically the mentally ill from these conferences? Ms. Hyde. Again, this is one event of many that we have worked with---- Mr. Johnson. But it is paid for by the taxpayers, correct? Ms. Hyde. It is one event that SAMHSA funds. Mr. Johnson. But it is paid for by the taxpayers, correct? Ms. Hyde. Well, SAMHSA uses taxpayer dollars---- Mr. Johnson. There you go. Ms. Hyde [continuing]. That is correct. Mr. Johnson. OK. Ms. Hyde. But it is only one. We have many others. The effort is to provide information and to provide assistance, for example, trying to provide help and information about how people can enroll in coverage to get access to treatment and services. We provide information there on different types of treatments and approaches that will help individuals. We try to develop workforce efforts there. There is a number of opportunities that we do at that conference, as with many of the other conferences that we support. Mr. Johnson. Mr. Chairman, I yield back. Mr. Murphy. Thank you. I now recognize Mr. Tonko for 5 minutes. Ms. DeGette. Will the gentleman yield to me just for one question? Mr. Tonko. I would. Ms. DeGette. Thank you. I just want to ask you quickly, Administrator Hyde, irrespective of whose fault the sequester was--and I don't think it was my fault because I voted no--but irrespective if it is the White House or the Congress' fault, the fact is that the cuts have gone into effect and your agency still has to administer those cuts, correct? Ms. Hyde. Correct. Ms. DeGette. Thank you. Thank you, Mr. Tonko. Mr. Tonko. Thank you, Ranking Member DeGette. And thank you, Mr. Chair. Thank you as well to Administrator Hyde for your testimony here today on the sequestration rundown. I think one piece was left out that the Democrats in this House proposed an alternative to sequestration. It was blocked by the majority in the House. Like many of my colleagues, I, too, am concerned over allegations of wasteful spending and the questionable activities of some SAMHSA grantees. These incidents should and will continue to receive the utmost scrutiny from this committee and I applaud the chair's initiative to conduct this important oversight hearing. However, I also have significant concerns that the instincts of some of my colleagues in investigating these allegations would be to throw the proverbial baby out with the bathwater resulting in further damage to our Nation's already reeling mental health system. This is not the right approach. And according to the National Association of State Mental Health Program Directors, States have cut at least $4.35 billion in public mental health spending from 2009 to 2012. In these tough times, federal funding from sources like SAMHSA's Community Mental Health Sources Block Grant is more important than ever to ensure that even more individuals do not fall through the cracks of our fragmented mental health systems. Administrator Hyde, that being said, I think the two biggest criticisms lobbied against SAMHSA are its funding of the Consumer and Consumer-Supporter Technical Assistance Centers and the Protection and Advocacy for Individuals with Mental Illness program. Can you tell us what proportion of SAMHSA's mental health budget in 2013 was spent on these very programs respectively? Ms. Hyde. Congressman, I don't have that number off the top of my head but I can tell you it was miniscule compared to the overall expenditures. We can get that. Mr. Tonko. Sure. Ms. Hyde. We can do the math and get you that information. Mr. Tonko. Well, according to my information, SAMHSA's 2014 budget request document, the Consumer Technical Assistance Centers program was funded at a level of 1.9 million and the Protection and Advocacy for Individuals with Mental Illness program was funded at 36 million. Together, these programs would comprise a little more than 3 percent of SAMHSA's $954 million mental health budget in 2013. If you could check on those numbers, please, Administrator Hyde---- Ms. Hyde. Will do. Mr. Tonko [continuing]. I would appreciate it and get back to the Committee. And by contrast, what percentages of SAMHSA's mental health funding went directly to States to support mental health treatment services in 2013? Ms. Hyde. About 48 percent of our mental health dollars went to States through the block grant program. There are additional discretionary grant programs that States have dollars from. Again, we could add up how much of that is States. Most of our dollars do go towards States. Mr. Tonko. So when you say most, like a rough percentage would be? Ms. Hyde. Again, I don't know how many of our grantees are States versus communities sitting here, but we can certainly get you that information. Mr. Tonko. It appears as though a vast majority of the dollars are going toward assistance for treatment. Regardless of how much money is spent on programs such as the Consumer and Consumer-Supporter Technical Assistance Centers and the Protection and Advocacy for Individuals with Mental Illness, these programs should be accountable for spending taxpayer money wisely. I share the opinions of many on this committee that grantees should not be able to use federal funds to lobby against duly enacted state laws. Can you describe what type of internal safeguards SAMHSA has in place to ensure that these monies are spent appropriately? Ms. Hyde. We review the grantee expenditures to assure that they are being spent on the issues that were identified in their applications and that the funding allows. If we are--if someone brings to us an allegation that those dollars are being spent inappropriately, we investigate that and act accordingly. Mr. Tonko. Thank you, Administrator Hyde. In closing, I would just like to point out that many of the programs that we are scrutinizing here today such as the Protection and Advocacy for Individuals with Mental Illness program saw their congressional authorizations expire at the end of 2003. Simply put, as a Congress, we have been derelict in our duty to provide proper and continuous oversight to this agency, and as such, this agency shares in the responsibility for any failures at SAMHSA. I would strongly urge my colleagues on both sides of the aisle to continue this dialogue and to work to enact meaningful legislation that will provide SAMHSA with the appropriate congressional guidance it needs to find out what works and what doesn't and to ensure it is meeting its core mission of serving individuals with serious mental illness. I stand more than ready to work on this goal with anyone who will join. And with that, Mr. Chair, I yield back. Mr. Murphy. The gentleman yields back. I now recognize the gentleman from Louisiana, Mr. Cassidy, for 5 minutes. Mr. Cassidy. Hello, Administrator Hyde. Ms. Hyde. Hi. Mr. Cassidy. A couple things. Clearly, we are in a time of budgetary constraints. You referred to it multiple times, but on the other hand, that is the new reality. That said, it seems a luxury to be unfocused in how we are implementing programs. I had to step out several times, I apologize, but I gathered one of the things I heard you say is that there are many working definitions of severe mental illness. Now, truly, this seems like an area that you, your agency could give guidance as to what severe mental illness is about. One example, one of the witnesses on the next panel speaks about how there is an unbalance in your compendium of care. She formerly worked with yours, says that of 288 programs listed, only four would address things pertaining to schizophrenia or bipolar disease. Now, first, knowing that our money is tight, why out of 288 programs will we only have four that seem to directly pertain to what we could all agree would be severe mental illness? Ms. Hyde. I don't agree with those numbers. I don't know exactly where that comes from. Mr. Cassidy. She is a psychiatrist formerly with SAMHSA. You can read her testimony but she ballparked it. She goes, listen, maybe there is a couple I missed. Let's say that there is 8, there is 12, but out of 288 it seems like 286 should be related to something that we could all agree was severe mental illness. Is something wrong with that logic? Ms. Hyde. The issue of serious mental illness is different for different purposes. So there is literally congressional definitions. There is definitions---- Mr. Cassidy. So I am coming back to the fact that knowing in a time of budgetary constraint, when, by the way, in the shadow of Sandy Hook I think we are compelled not to accept that there are a lot of different definitions but to try and hone down at least in programmatic funding upon something that if there was a psychiatrist at the Agency in a position of authority, she would say, wow, this is how we prevent another Sandy Hook, put our resources there as opposed to a lot of other things which are more diffuse. Ms. Hyde. I am not aware of any of SAMHSA's programs that are targeted to serious mental illness that doesn't include schizophrenia. It is not just---- Mr. Cassidy. OK. But our point is that there is---- Ms. Hyde [continuing]. Schizophrenia, however---- Mr. Cassidy [continuing]. A maladjustment of the compendium of care that there is only four programs--let's say for the sake of argument it is 12 out of 288 that are specifically focused upon what we could all agree would be serious mental illness. Ms. Hyde. I am sorry. I just don't agree with the numbers. As I told you earlier---- Mr. Cassidy. So if she comes up with that, would you agree in concept--because her testimony is next--in concept would you agree that if that is true that that would be an unbalanced compendium of care? Ms. Hyde. I don't agree that that is true. Mr. Cassidy. But if it were true, would you accept that, just a hypothetical if you can go with me that there really should be a focus of these programs--in fact, your answer implies that you think it should be. There should be a focus of these programs upon those that we can agree would be severe mental illness? Ms. Hyde. I think I have said several times there is a priority on serious mental illness. Mr. Cassidy. And how do you define priority? Ms. Hyde. Seventy-five to eighty percent of our funding for mental health goes to people with serious mental illness or serious emotional disturbance, which is---- Mr. Cassidy. OK. Ms. Hyde [continuing]. The name for our children's programs. Mr. Cassidy. OK. Now, that said, severely mental ill patients, I see a lot of these grants go for prevention, but you can't really prevent paranoid schizophrenia. I mean we don't know the biologic basis in terms of a prevention activity. Ms. Hyde. Actually, there is increasing evidence that we can prevent the disability related to those psychotic illnesses, and the earlier we intervene, the more we can have a positive impact---- Mr. Cassidy. So when you say prevention, you don't technically mean prevention of the illness; you mean prevention of the untoward effects of having mental illness. Ms. Hyde. Prevention has a range of issues in it. From--the Institute of Medicine has a whole range from primary prevention all the way up to intervention. Mr. Cassidy. Is there primary prevention of paranoid schizophrenia? Ms. Hyde. No, I don't think we have the ability to do that at this point. Mr. Cassidy. So my problem again, in an era of budgetary constraints, should we be focusing our dollars on that which actually would prevent another Sandy Hook or should we be more diffuse? And let me ask you that. Do you agree with that question? Ms. Hyde. I think we should do everything we can to prevent incidents like Sandy Hook. Mr. Cassidy. So does that mean again yes or no that we should focus our limited dollars upon those activities not exclusively but would primarily focus our limited dollars on those activities that would definitely have the potential to prevent such an incident like that? Ms. Hyde. I think that is why the President has proposed the 2014 budget, several programs that we believe will help identify that and help---- Mr. Cassidy. And so you do agree that we should focus our dollars because that is actually not a yes or no answer. And I don't mean to be confrontational, but that is---- Ms. Hyde. We have no choice as public administrators but to focus our dollars and we do that every day. Mr. Cassidy. OK. Great. I am almost out. I yield back. Mr. Murphy. I thank the gentleman. I just want to point out, I am looking at a document that SAMHSA put out called Mental Health: United States 2010. And in that on page 11 SAMHSA does define serious mental illness. Among adults, it is defined as ``persons 18 or older who currently or at any time in the past year had a diagnosable mental, behavioral, or emotional disorder and resulting in substantial impairment in carrying out major life activities.'' So I am assuming diagnosable. So you do have a definition. I know we have been going back-and-forth on that but that is helpful and I should focus on that. We have finished our questions but I do want to ask a favor of you if I can. I know one of the things that you have said frequently is you are not aware about some of the programs you fund and you asked for some of our feedback on those. So I have a personal request. On the next panel a man named Joe Bruce is going to testify and I know you are very busy, but Mr. Bruce's testimony, he said he is going through something that no parent or husband should ever have to experience. His son William, after being discharged from a mental health treatment center with the assistance of a representative from the SAMHSA-funded Protection and Advocacy for Individuals with Mental Illness program murdered his mother. And it is also Mr. Bruce's wife, and he murdered her with a hatchet. I believe his story is very powerful and important and I think it is important for you to hear what one of the agencies you funded has done in this instance. So if you can stay just to hear his 5 minutes of testimony, I would be grateful if you could do that. And with that, we end this panel and we will prepare the second panel to come up. Thank you. Ms. Hyde. Thank you. Mr. Murphy. I will start to introduce our witnesses as they are taking their seats. I will introduce the witnesses of the second panel. Our first witness is Joseph Bruce, the father of a son who suffers from severe mental illness. Our second witness is Dr. E. Fuller Torrey. He is a research psychiatrist specializing in schizophrenia and bipolar disorder and founded the Treatment Advocacy Center and executive director of the Stanley Medical Research Institute, which supports research on schizophrenia and bipolar disorder. He is also a professor of psychiatry at the Uniform Services University of the Health Sciences. Our third witness is Dr. Sally Satel, a psychiatrist trained at Yale University School of Medicine. Since 2001 she has been a resident scholar at the American Enterprise Institute and also continues part-time clinical work in drug treatment clinics in Washington, D.C. And our fourth witness is Dr. Joseph Parks. He is the chief clinical officer at the Missouri Department of Mental Health. There, he is responsible for clinical standards and quality of care for persons with mental illness, mental retardation, and developmental disabilities and alcohol and drug dependence. In this capacity, he has substantial experience working on SAMHSA- funded grants. I will now swear in the witnesses. And you are aware the Committee is holding an investigative hearing. When doing so, we have the practice of taking testimony under oath. Do any of you have any objections to testifying under oath? All have responded no. The chair then advises you that under the rules of the House and the rules of the Committee, you are entitled to be advised by counsel. Do you desire to be advised by counsel during your testimony today? All have said negative. In that case, if you would please rise, raise your right hand, I will swear you in. [Witnesses sworn.] Mr. Murphy. Let the record show all witnesses have answered in the affirmative. You are now under oath and subject to the penalties set forth in Title XVIII, Section 1001 of the United States Code. You may now each give a 5-minute summary of your written statement. I will call upon you first, Mr. Bruce, for your statement. Thank you for being here. TESTIMONY OF JOSEPH BRUCE, FATHER OF A SON WITH SEVERE MENTAL ILLNESS; E. FULLER TORREY, FOUNDER, TREATMENT ADVOCACY CENTER; SALLY SATEL, RESIDENT SCHOLAR, AMERICAN ENTERPRISE INSTITUTE; AND JOSEPH PARKS, III, CHIEF CLINICAL OFFICER, MISSOURI DEPARTMENT OF MENTAL HEALTH TESTIMONY OF JOSEPH BRUCE Mr. Bruce. My name is Joe Bruce. I live in Caratunk, Maine. On February 6---- Mr. Murphy. Pull the microphone real close to you, please. Thank you. Mr. Bruce. On February 6, 2006, my son William Bruce, age 24, was involuntarily committed to Riverview Psychiatric Center in Augusta, Maine. On April 20, 2006, with help from federally funded patient rights advocates from the Disability Rights Center of Maine, Will was discharged early from Riverview without the benefit of any medication. As is most often the case with severely and persistently mentally ill persons across the country, Will returned home. Fears his mother and I had voiced to his doctors that Will would hurt or kill someone came true. On June 20, 2006, I returned home to find the body of my wife Amy. Will, in a state of deep psychosis, had killed her with a hatchet. Will was advised that without his consent, his parents had no right to participate in his treatment or have access to his medical records. Will believed there was nothing wrong with him and that he was not mentally ill, a condition characteristic of many persons with severe bipolar disorder or paranoid schizophrenia, particularly of younger ages such as Will's. He would not consent to our involvement with his treatment, and because he was an adult, his mother and I were barred from all access to his treatment. The doctor's decision to release him, which resulted in such a tragic outcome, was made without the benefit of all of Will's history or any input from Amy and me. After his commitment to Riverview by the criminal court, I applied to become his guardian. Will was agreeable to this until, incredibly, a patient advocate told him the guardianship is a bad idea. It would give your father complete power over you. The attending physician, a new doctor, undoubtedly at the urging of DRCM, refused to provide the evaluation required in the guardianship application. He told me, I could never participate in anything that would cause your son to be considered an incapacitated person. Bear in mind that at this point in time, Will had been placed in the hospital after being found incompetent to even stand trial. Suffice it to say, I finally did become guardian, and I was able to participate in Will's treatment and to obtain the medical records of his prior treatments. Until then, I had not known the role that patient advocates had played in Will's premature and unmedicated release. The medical records revealed exactly what the patient advocates had recklessly done and said to encourage Will to avoid the treatment he so desperately needed. His doctor had recorded verbatim what the patient advocates said to Will in the meetings from which Amy and I had been excluded. The patient advocate, a Trish Callahan, told the treating doctor that DRCM regarded Amy and me as a ``negative force in Will's life.'' Amy and I had never met any of these people or even heard of Disability Rights of Maine. In the treatment meetings, she acted like a criminal defense lawyer. She openly coached Will on how to answer the doctor's questions so as to get Will the least treatment and the earliest release. She did this in the face of strongly contrary evidence of Will's unsuitability for unmedicated release. She repeatedly pressed for his early release despite knowing or recklessly disregarding that he was unsuited for it. DRCM willfully neglected Will's need for treatment, and their pressure on the doctor to release Will led directly to Amy's death. But neither the patient advocates nor the DRCM has ever acknowledged they did anything wrong. They have not changed their procedures, and Trish Callahan, the advocate who helped fuel Will's paranoid hostility towards his mother and contributed to her death, continued to work on the same unit at Riverview for years afterwards. Lest anyone believe this is a local, isolated occurrence, the National Disability Rights Network, responding to the Wall Street Journal's page 1 article concerning Will's case, defended the actions of DRCM, and even prepared talking points to deflect criticism. The patient advocates can do this with impunity because they are literally accountable to no one. But my experience with the patient advocates did not end here. I have come to know the stories of many families, and their experience with the advocates' surprising approach to these issues. Beginning in 2007, I joined with other family members of some of the most severely mentally ill individuals in the State of Maine to seek legislative change to laws that had prevented our loved ones from receiving treatment. We took our concerns to the lawmakers in the Maine legislature. To the shock of all of us, we met with fierce lobbying opposition from Disability Rights Center of Maine. Nonetheless, we were successful in obtaining helpful legislation in 2007 providing for medication over objection in appropriate cases. Having failed in the legislature, the lawyers at DRCM filed a legal action challenging the law, which thankfully was unsuccessful. At the time of Amy's death, the courts in Maine only had two options at a commitment hearing: to place someone in the hospital or to release them unconditionally. In 2008 and 2009 I and other family members worked to give the court a third option, that of releasing an individual into the community on the condition that he remain on medication. These types of laws are known as Assisted Outpatient Treatment laws and they have been opposed across the Nation by PAIMI organizations. Maine was no exception. DRCM mounted a well-orchestrated attack on the proposed AOT law. It was joined in this effort by the Advocacy Initiative Network of Maine, another SAMHSA-funded organization. Their campaign included proffering 20 or so consumer witnesses in opposition to the law, but these consumers were completely aware of their mental illness, stable on medication and successfully living in the community, the very goals that the proposed law was designed to achieve for our loved ones. DRCM had persuaded them to oppose the law by misrepresenting its essential provisions. This cynical opposition to the AOT law-- which failed, because the law was ultimately enacted--shocked me and the families. The incident illustrates the national policy of the PAIMI program to oppose any form of involuntary treatment. The PAIMIs, like DRCM, are so concerned that one person may be inappropriately treated involuntarily that they seek to prevent anyone from being medicated. In Will's case, once I became his guardian, medication over his objection was his route to recovery. As another example of DRCM's lobbying influence in this area, while the Maine families and I were busy working on the AOT law, DRCM was successful in getting a bill through the Maine legislature to make it more difficult for families to become guardians. Becoming a guardian is the only way families of adult patients can be involved in the treatment of their loved ones where the patients are unwilling or unable to consent. Why do PAIMIs want guardianship to be more difficult? Because guardianship lifts HIPAA secrecy and allows the guardians into the treatment meetings. Will is still in Riverview, to which he was committed by the criminal court. Once he was committed, he got the care he should have gotten before. Ironically and horribly, Will was only able to get treatment by killing his mother. We have found a medication that works. He leaves the hospital frequently on supervised release with staff or family members. He is being successfully treated and he is doing extremely well. He now recognizes that if he had been treated, his mother would still be alive today. He stated to the Wall Street Journal, ``the advocates didn't protect me from myself. None of this would have happened if I had been medicated.'' Tragedy visits families every day. That is a sad fact of life. But an unbearable aspect of Amy's death is that my own tax dollars helped make it possible. A retired nurse from Riverview may have summed it up best. She wrote: ``Mr. Bruce, your losses didn't happen for reasons other than your family's misfortune to become involved with the mental health system, when politics now overrides sound medical decisions.'' Thank you for hearing my testimony. I would be happy to answer any questions. [The prepared statement of Mr. Bruce follows:] [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] Mr. Murphy. Thank you, Mr. Bruce. And our hearts are with you and your family. I know you made references to a number of documents. You ask that these be submitted in the record and the minority has no objection. We will include these in the record then. Thank you. Dr. Torrey, you are recognized next for 5 minutes. TESTIMONY OF E. FULLER TORREY Dr. Torrey. Thank you very much. Mr. Murphy. Microphone on and close to your mouth, please. Dr. Torrey. Thank you very much, Chairman Murphy, Ms. DeGette. Very, very important what you are doing. It is not as sexy as the IRS hearings but it is just as important. I am here to describe why I think SAMHSA is not only a failed federal agency but it has been so for 30 years. That is one of the qualifications I don't like. This is not a new issue. This is not just something that falls on Ms. Hyde. This is something that has been going on for 30 years really unlooked at by Congress in any serious--and so I strongly commend you for doing what you are doing. I also want to emphasize that is not a Democratic or Republican issue. The--SAMHSA has been a failed agency. It was originally put together under the Bush Administration. It was a failed agency under the Clinton Administration, under the George Bush Administration, and it is continuing to be a failed agency under the Obama Administration. I would like to illustrate that by six points. Point number one--and I am emphasizing what they should be doing compared to what they really are doing. Mass killings are increasing. We have heard that today. About half of the mass killers have serious mental illness, mostly schizophrenia, Seung-Hui Cho, Jared Loughner, James Holmes being only examples of them. There is no question they are increasing. SAMHSA does not seem to see this is a--this is not a priority for them at all. We have talked about the fact that their 3-year plan has nothing about these problems but talks completely about behavioral health problems. A 4-year-old with tantrums having behavioral health problem, I understand that. A 12-year-old skipping school has problems. Somebody who goes down and kills 30 first-graders doesn't have a behavioral health problem; he has a severe mental illness and that should be recognized as such. We now know that these are severe mental illnesses. I have a tremor of my left hand that is an early Parkinson's disease. This is not a behavioral health problem; this is a brain disease, just as schizophrenia, bipolar are brain diseases. These are twins that we looked at many years ago, now showing the one on the right who has schizophrenia, identical twins, has larger ventricles. There are now literally hundreds of studies showing that severe mental illnesses like this are brain diseases on it. Severe mental illness has been defined for Congress. It was defined by the mental health NIMH Advisory Council at the request of Congress in 1994 on it. SAMHSA does not understand. It has no expertise on severe mental illness. Its last psychiatrist who had any expertise, Ken Thompson, left 3 years ago. The one psychiatrist was retained as an expert only on substance abuse, and the psychiatrist they just hired only has expertise on substance abuse, a very good woman but has no expertise on severe mental illness. When SAMHSA was asked to bring a psychiatrist to testify before the Vice President Biden's committee, they brought in Dr. Daniel Fisher, who doesn't believe schizophrenia exists. He thinks it is a severe emotional distress, a spiritual experience. Mr. Cho and Loughner and Holmes were not having a spiritual experience. They were having a brain disease that needs treatment. We have effective treatments. We have medication, we have assisted outpatient treatment. We know that assisted outpatient treatment will decrease hospitalizations in several different studies, decrease homelessness in one study, decreased victimization, decrease arrests in four studies, decrease violent behavior in three studies, and saves money in two studies. We have all kinds of evidence that this is a very effective treatment for people, especially who don't recognize that they are sick. There is no evidence of that at all in SAMHSA, and in fact, SAMHSA has funded, as you have already heard today, programs, in my count, 14 States protection and advocacy consumer groups that have actively opposed the use of outpatient--assisted outpatient treatment and other effective treatments, including the States of many members of this committee on it. Three, there is the issue of the unawareness of illness, and we know now there is about 20 studies showing the people who are not aware of their illness have differences in their brain, those people with schizophrenia on it. We need to pay attention to that. Instead, what they do is they find Alternatives Conference, as you have heard. I will answer the question from the Congressman of Tennessee. We estimate the cost of a single Alternatives Conference is about $500,000, and although SAMHSA appears to be feeling that they are short of money, 2 weeks ago they funded and approved for funding the conference for this year on it. Another issue is the shortness of psychiatric beds. SAMHSA doesn't pay any attention to that but does have an international office and has an interest in psychiatric beds in Iraq and held conferences in Cairo and Amman on that. Severe mental illness in jails and prisons is about 400,000. This is not a priority for SAMHSA. SAMHSA instead is concerned with putting out reading books, ``Wally Bear and Friends,'' sticker books, et cetera. Finally, last but not least, federal money to support severe mental illnesses are among the fastest-growing items in the federal budget, including federal funds for psychoses. That was the most expensive of all the nine chronic diseases, three times more expensive than the cost of diabetes on it. SAMHSA, this is not a priority. In 2010 I asked about several questions about, for example, why do some States have three times more patients on severe mental illnesses on SSI and SSDI? SAMHSA had no answers to any of these questions and did not answer, and the reason why I know they didn't have any is because they were very busy. Number one, they were---- Mr. Murphy. The gentleman's time is expired. Can you wrap up with a final moment? Are you ready to wrap up? Dr. Torrey. Sorry. Mr. Murphy. So your time expired. Can you wrap up with whatever final statements you are going to make on this? Dr. Torrey. Ten seconds of a video? Mr. Murphy. Yes. [Video shown.] Dr. Torrey. This is what they were spending $80,000 on, which is their annual songfest that they have in early December on it. This cost about $80,000 and involved all the members and was their attempt to bring attention to substance abuse. And my argument is that people who have $109,000 as an average salary don't need to be told that substance abuse is a big issue on it. Thank you very much. I just want to again emphasize how important what you are doing is. And if Congress doesn't act at this point, then we are going to have additional problems under the next Clinton or the next Bush or the next Obama Administration. Mr. Murphy. Thank you. Dr. Torrey. Thank you. [The prepared statement of Dr. Torrey follows:] [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] Mr. Murphy. Dr. Satel, you are recognized for 5 minutes. TESTIMONY OF SALLY SATEL Dr. Satel. Thank you, Representatives Murphy, DeGette, and---- Mr. Murphy. Microphone, and pull it close. Thank you. Press the button so it is green. Dr. Satel. Thank you for inviting me to be here today. Mr. Murphy. It is not on yet. Do you have a green button? It is lit up? Dr. Satel. I apologize. Mr. Murphy. Thank you. Dr. Satel. Thank you for inviting me to be here today. I am a resident scholar at the American Enterprise Institute, and as a psychiatrist, I do some work at a local methadone clinic. And from 2002 to 2006 I was a member of the National Advisory Council of the Center for Mental Health Services. My point today is that SAMHSA does not adequately serve the sickest individuals despite its statutory mission to do so. To start with, the Agency has adopted an idiosyncratic interpretation of its very mission. I am referring to something called the Recovery Model. The Recovery Model, according to SAMHSA's definition as its guiding philosophy, is ``a process of changes through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.'' Well, living a self-directed life and reaching one's full potential is an excellent aspiration and I try to accomplish that with my patients as well, so I am not here to criticize the spirit of that model. What I am here to do is to underscore how inappropriate it is for the sickest patients. We are talking about individuals here who are too psychotic to participate in their own self- directed life, too paranoid, too terrorized by hallucinations, too lost in delusional thoughts. Fifty percent of them, as Dr. Torrey just alluded to, don't even recognize they have an illness, and if they don't have insight into the problem, there is no way they are going to be able to ``collaborate in creating a detailed life plan,'' which is part of SAMHSA's agenda for the mentally ill, or ``determined their own unique path.'' They are the most vulnerable of CMHS's constituency. They are the sickest silent minority who languish in back bedrooms and jail cells and homeless shelters. And CMHS does not hear from them. Instead, they hear from consumers, which is the word--politically correct word for patient--consumers who are able to be directed. They don't hear from the folks who are most impaired, nor do they hear from their caregivers, the clinicians who get their hands dirty in the trenches with these most desperate patients, or even from some of those patients themselves who, once they are improved, can acknowledge that mainstream psychiatry has been helpful for them and medications as well. They don't hear from them. They hear from consumer survivors who claim to speak for all patients, but obviously don't do that. This imbalance has concerned me for years. When I was on the Advisory Council from 2002 to 2006, we repeatedly were trying to have some input into the decisions regarding the grants that were approved but it was clear that we were pretty much there to rubberstamp those grants. They had already been approved. We asked repeatedly if we could see them prior to approval or if we could review them after approval and then have our assessment be reconsidered, and we were turned away every time. My colleague--I mentioned a colleague--actually, his name should appear in my testimony. It is Dr. Jeffrey Geller, who is a professor at University of Massachusetts, but he followed me or we overlapped a bit on the Council, and what he told me was he and fellow members during those years just gave up at attempts for meaningful input and left in disgust. Finally, I will turn to the kinds of programs that serve as a model for the kinds of programs that SAMHSA hopes, states will enact. This is through--it is a national registry of evidence-based programs and practices. And here, there is a striking imbalance. What I mentioned in my testimony was of the 228 programs, four specifically mentioned severe mental illness in their description. Now, that doesn't mean only four attend to severe mental illness, but it is striking that even some of the others who did not mention severe mental illness talked about patients who were--I will give you one example here-- designed for patients motivated to manage their mental health issues. Again, these are patients whose psychotic symptoms are in check. They are not the most disturbed. And what is also very striking about this registry of programs is the fact that it pointedly omits AOT, assisted outpatient treatment. As Dr. Torrey described what those are, I won't go into it. Briefly, a word about prevention. No, we cannot enact primary prevention in the mentally ill, severely mentally ill. We don't understand the brain mechanisms yet that cause it. I will end with two recommendations. One would be really to Administrator Hyde, which is to abandon the Recovery Model that is the umbrella philosophy and take advice as well from parents, clinicians, and the sickest but improved patients who have something constructive to offer. Don't fund groups that are anti-psychiatry in their agenda. It is like the CDC funding activists who would tell people with HIV not to take their antiretrovirals or not to have protected sex. And consider directing the Secretary to commission an independent review of the scientific soundness of the studies listed on that registry about which ones are there and which ones are missing and should be included. Thank you very much for your time. [The prepared statement of Dr. Satel follows:] [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] Mr. Murphy. Thank you, Dr. Satel. Dr. Parks, you are recognized for 5 minutes. TESTIMONY OF JOSEPH PARKS Dr. Parks. Good morning. I am Joseph Parks. I want to thank the chairman and Congresswoman DeGette for the opportunity to testify today. I am testifying today in my individual capacity and not on behalf of any organization. I am a board-certified psychiatrist with specialty training in emergency psychiatry. I have served as the medical director for the Missouri Department of Mental Health for 20 years. For 3 years, I was the director of its overall mental health operation. Throughout my career, I have continued to see patients and I still see patients on a weekly basis. I have provided psychiatric service to harmlessly mentally ill persons in shelters and through assertive community treatment teams. For the past 12 years I have been the president of the Medical Director Council of the National Association of State Mental Health Program Directors, and for the past 3 years, I have served as director of the Missouri Institute of Mental Health and professor at the University of Missouri St. Louis. Through my various roles, I am very familiar with the SAMHSA Mental Health Block Grant and the Discretionary Grant programs. These programs are an important contribution to improving the lives of people with serious mental illness. I have been a principal investigator for SAMHSA Discretionary Grants, I have independently evaluated grants through my role at MIMH, and as Missouri Mental Health Division director, I was responsible for the execution of the block grant plan. Although the amounts are modest and inadequate to meet the overall needs, the SAMHSA Mental Health Block Grant plays an important role in funding services for uninsured persons and services that are not payable through Medicaid, particularly in young adults who are not usually insured when they first become ill. Block grant funding has been especially critical to keep in place the full range of activities and services that a comprehensive state mental health system wants to have, including early identification and early intervention. I specifically want to mention to the Committee that SAMHSA requires us when using the block grant if we are funding individual activities to spend them on persons with serious mental illness or children with SED. That is a requirement of how we use those funds. Now, SAMHSA discretionary grants play an important role in implementing new evidence-based practices and improving the quality of care to people with serious mental illness. A good example is SAMHSA's Co-Occurring State Incentive Grants--they were called COSIG--which helped us improve the ability of community mental health centers and substance abuse treatment agencies to promptly and effectively serve people who have both mental illness and substance abuse conditions simultaneously. This is particularly important with respect to reducing violence by people with serious mental illness. The discretionary grants also fund technical assistance. In Missouri we got technical assistance to reduce the use of seclusion and restraint in our state hospitals, which reduced both patient and staff injuries. Before I turn to policy recommendations, I would like to acknowledge in light of Oklahoma's tornadoes that SAMHSA gave significant support when we had tornadoes in Joplin in 2011 in Representative Long's district. They were instrumental in us getting care out to those people rapidly. I want to make the following recommendations for improving treatment for people with serious mental illness and reducing violence: first, there is a growing shortage of psychiatrists. We need a national approach to increase the psychiatric workforce. Demand for psychiatric services is far outstripping the ability of the available workforce to supply timely needed care. Aging psychiatrists are retiring out faster than new graduates are taking their place. The current estimated gap by the EPA is about 45,000 psychiatrists short. Patients are not being seen for months and clinic and hospital psychiatric units are closing because they can't get the staff. There needs to be attention here. Second, I would like to make recommendation for two specific discretionary grant directions. There should be grants available to implement mental health first aid training. This is an early identification, early intervention for mental illness that is a training with the general public similar to regular first aid. It is a national--it is being implemented nationally but it needs more support to roll it out to get people engaged before they become suicidal or violent. Third, there needs to be a new round of the COSIG grants. Substance abuse increases the likelihood that somebody will be mentally ill significantly. Over half of people with mental illness have substance abuse problems. We need new grants in this area. Regarding mandatory treatment, I would actually recommend greater support for mental health courts. I have been involved in providing mandatory treatment through different legal modalities, including inpatient and outpatient civil commitment, guardianship in mental health courts in three different States. In all three States the outpatient--had outpatient commitment laws and in all three States they were difficult to implement and used rarely primarily because local law enforcement doesn't have the resources and doesn't want to use their officers to follow up on people that are violating the commitment orders. Also, it is--mental health courts are more agreeable--are more acceptable to the courts, to law enforcement, and to the people with mental illness. I think they would be the best strategy. Finally, to end my comments, there is an epidemic of premature death among people with serious mental illness. Research shows that people in the public mental health system, most of whom are seriously mentally ill, die an average of 25 years younger--in their mid-50s--than the general population. This is shorter than the life expectancy of someone with HIV and on a pier with sub-Saharan Africa. It is an unaddressed national tragedy. People with serious mental illness should be federally designated as a health disparities population and their rates and causes of death should be monitored annually. HHS and SAMHSA should develop a national strategy that Congress should fund specifically for reducing these premature deaths, most of which are due to chronic medical conditions due to poor care. We need to promote the integration of behavioral health and general medical care and promote integrated preventive measures on both the healthcare side and the mental health side. Nobody recovers from their mental illness once they are dead of a heart attack, and that is what is killing our people with serious mental illness. Thank you for the opportunity to present my views on these critical issues. I would be happy to assist the Committee in my various roles to help you implement solutions and address the needs of people with mental illness. This deserves national attention and leadership at all levels. It is greatly appreciated you holding this hearing. [The prepared statement of Dr. Parks follows:] [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] Mr. Murphy. Thank you. I just recognize myself for 5 minutes. Dr. Parks, you are opposed to assisted outpatient treatment; you say so in your written and oral testimony? Yes or no? Dr. Parks. I think--no, I don't think I can make a yes/no answer. What I am advising the Committee of is if you wish to increase access using mandatory methods, I think you will be more successful and get better implementation if you focus on mental health courts. Mr. Murphy. I understand, but with regard to getting treatment, courts don't provide treatment. Assisted outpatient treatment is an alternative that has been--we have heard testimony, read things that have been fought by some of these advocacy groups funded by SAMHSA. Dr. Torrey, do you think assisted outpatient treatment, mandatory assisted outpatient treatment has a value and is there evidence to prove that? Dr. Torrey. Obviously, assisted outpatient treatment is a proven entity at this point. Mental health courts are also good but it is important to recognize that mental health courts are merely being used because of the failure of the mental health treatment system as such. The other problem with mental health courts is you can't get treatment until you have broken a law, so if I said to you today we have a very good treatment for people with diabetes or hypertension but you have to break a law to get it, you would probably say that I deserve some treatment. This is the problem of where we are now that we don't have any real treatment system out there and we are having to use the mental health courts. That is a sign of the failure of the system, not the good part of the system. But they work. Mr. Murphy. And Mr. Bruce, in your testimony, do you believe that if your son had been court-ordered to receive other treatment, inpatient or outpatient, that an outcome could have been different for him? Mr. Bruce. There is no question about it. He---- Mr. Murphy. It is on. Just pull it closer. It was on. There you go. Now, it is off. The green light needs to be on. There should be a green light on there. Thank you. Mr. Bruce. My son responded to medication immediately. The testimony of Dr. Schottky at--a forensic psychiatrist who evaluated him for his trial talked about the difference between Will before--when she met him the first time unmedicated and then when she spoke to him again later after he had started taking Seroquel, and I knew immediately that he was on medication because he called me for the first time in 4 months or so and he was in tears and he said, Dad, I am sick. And he is--Seroquel was not the right medication for him. He later began taking Abilify. But I take Will out to lunch in Augustine, Maine. We go shopping together. He--if you were to talk to him now, you wouldn't--there is no sign of delusions. He is able to plan and think. He has problems because of the length of time that he remained psychotic, but he is--if he had been on medication in 2006 and had been released from the hospital on a court order that said he had to remain on his treatment plan, that would have given him an opportunity for the medication to work and with the supporting treatment that is necessary in these kind of programs, I think that he would be living in a community somewhere probably with a job, and life would be a lot different for the Bruce family. Mr. Murphy. Thank you. Real quickly from each of the doctors I want to ask you a question. In the SAMHSA administrator's testimony she talked about the 5,000 additional mental health professionals also requested by the President, and listed in there to train social workers, counselors, psychologists, behavioral health professionals, marriage and family therapists, nurses, and other mental health professionals. Dr. Torrey, yes or no, do you think this should also include psychiatrists? Dr. Torrey. Absolutely. I worked at the National Institute of Mental Health for many years. I can't conceive of a federally administered program for people with mental illnesses that does not include psychiatric input on it. Mr. Murphy. Dr. Satel, do you think funding should also increase to get more psychiatrists? Dr. Satel. Of course. Mr. Murphy. And Dr. Parks, you already said so? Dr. Parks. The shortage is more severe for psychiatrists than the other categories. Mr. Murphy. Particularly child psychiatrists, I believe. Dr. Parks. Particularly child psychiatrists, horrible shortage. Mr. Murphy. I would just like to conclude with one other comment. When it comes to court-ordered inpatient or outpatient treatment, it is extremely important to note that unless a legal procedure takes place for inpatient or outpatient treatment by a court proceeding, that person's name does not go on the National Instant Background Check. Quite frankly, we don't know how many people should be on that list and the NICS list is what is used to determine if someone should be permitted to buy a gun. And while people are advocating whether or not we should expand registration, my concern is that we may not be putting people on that list who are at risk of abusing a weapon for an attack. I yield now to Ms. DeGette for 5 minutes. Ms. DeGette. Thank you, Mr. Chairman. And Mr. Bruce, your experience is heartbreaking and as a mom, you know, I want to give my deepest condolences to you and all the issues that you continue to work through to this day. And I also want to say I think this assisted outpatient treatment should be a tool that psychiatrists and mental institutions are allowed to have. Forty-four States allow that right now. And, Dr. Parks, maybe you can answer this. I think that in the block grants that SAMHSA gives to the States, they would be able to use that money for the assisted outpatient treatment if they decide to do that, correct? Dr. Parks. That is correct. Ms. DeGette. Thank you. Dr. Parks. And to answer the chairman's question, I do not oppose assisted outpatient treatment---- Ms. DeGette. You don't oppose it either but---- Dr. Parks. It is difficult. Ms. DeGette. So in my previous life before I came to Congress I was a practicing lawyer, and I think everybody kind of alluded to this, including you, Mr. Bruce, which is if you are going to get in order for assisted outpatient treatment, that is going to have to be in order that is given by somebody. And I think maybe, Dr. Parks, that is what you are talking about when you talk about these mental health courts. Is that part of it? Dr. Parks. Assisted outpatient treatment is a civil court order and a mental health court is a criminal court order. Ms. DeGette. OK. So this would be a---- Dr. Parks. But either is a court order in either case. Ms. DeGette. OK. But it is a court order. And so one thing I think--and this goes to our whole discussion we are having today--is that we have just woefully underfunded our entire mental health system in this country because if you are going to do a court order, which is appropriate in many cases, then you have to have the resources to enforce that. And I have constituents coming in with very similar stories, Mr. Bruce, to yours. And, you know, one of the things we have learned in these hearings that we have been doing is that schizophrenia tends to manifest itself in young men between the ages of 19 and 25. So that is just the age that these young men are going off on their own. They are in college or whatever and they are above 18. And so, you know, the care providers of the colleges are not required to tell the parents. So this is the kind of tragedy we are hearing about and we don't have enough resources in our mental health system to target people like that and to help them. Dr. Parks, you are nodding your head. Do you want to---- Dr. Parks. Usually when I go to court to get either a civil order or to get a criminal condition of probation, it takes half a day. That means that there is 12 to 16 people I did not see in clinic because I was taking the time in court. Psychiatrists' time gets shorter and shorter and this is a choice agencies face. You know, I only have three---- Ms. DeGette. Right. Dr. Parks [continuing]. Psychiatrists. Do I do some more assisted outpatient treatment and tie up their time in testimony or do I try and just stay away from that? Ms. DeGette. And there are not enough resources to process those cases and there is not enough resources to treat the patients. I had a lady in Denver who said to me that her son, he became psychotic. He was committed. Then, he was on a 72- hour hold. He was released and then he came home and he said, Mom, I think I am going to kill you or myself. And she couldn't get him the help he needed. And everybody has stories like this. I just want to ask you a couple of questions, Dr. Parks, about the SAMHSA block grant program because a lot of people have been saying that a lot of SAMHSA's funding is not reaching people living with serious mental illness issues, and frankly, that is Congress' fault because of the way we budget it. But for the money that is used for mental illness as opposed to drug abuse, you have seen on the ground in Missouri funding from the SAMHSA Mental Health Block Grant. How much does Missouri get every year in that block grant? Dr. Parks. For the block grant we get approximately $7.5 million, a very moderate---- Ms. DeGette. And what percentage of the 7 \1/2\ million that Missouri gets is used to treat people that don't have health insurance? Dr. Parks. About 65 percent goes to people that are uninsured. Ms. DeGette. So if they didn't have that money from that block grant for mental health treatment, where would they be able to get mental health treatment dollars for your State? Dr. Parks. Where people usually go, the emergency room. Ms. DeGette. OK. And how much of SAMHSA's Mental Health Block Grant is used to treat patients diagnosed with a serious mental illness? Dr. Parks. Essentially all of it. There is a small amount used for suicide prevention that was approved and there is about 4.5 percent we are allowed to spend on administrative overhead, much lower than the 20 percent administrative overhead that commercial insurance is allowed. Ms. DeGette. So most of it is for serious mental illness? OK. Thank you very much, Mr. Chairman. Mr. Murphy. Thank you. I now recognize the gentleman from Texas, Mr. Olson, for 5 minutes. Mr. Olson. I thank the chair and welcome to our witnesses. A very special warm welcome to you, Mr. Bruce. I have seen a tragedy similar to yours. Two weeks before Christmas in 2003 a family of four from my church came home from dinner. A mass gunman was waiting for them. The wife was killed, the younger son was killed, the husband was severely wounded, and the oldest son was shot in the arm. The investigation took a course no one saw coming. Because of an irrational hate, the oldest son had hired a hitman to kill his family. I know your situation is different from that situation, but having talked to the father, I know the courage it takes to come here and testify. So I thank you for your courage and your strength to be here today. You will be in my family's thoughts and prayers. My question is for Mr. Torrey. Mr. Torrey, your first witness, you mentioned your 2010 request to SAMHSA for information, data on why federal costs in mental illness were increasing so rapidly and their response that there was no data. Have you received any information to your knowledge that SAMHSA has begun collecting this type of data? For example, in your testimony you said what if some States have more than three times more mentally ill individuals per population on SSI, supplemental security income, or on Social Security disability insurance than our States do? What is the percentage of mentally ill individuals on SSI, SSDI who are not receiving treatment? What is the percentage of Americans with serious mental illnesses who are receiving SSI and/or SSDI? And the answer you got? We have no data. Is that true? Dr. Torrey. Yes, it is. Mr. Olson. There is no data? Dr. Torrey. Yes, that is absolutely correct. And it is important to realize that we have $140 billion in the mental health treatment system right now. Everyone says we need more money. In fact, we have 12 times more, corrected for population, than we had 60 years ago. I am one of the few people in Washington who probably says we don't need more money; what we need to do is spend the money the way we should be spending it and focus on the seriously mentally ill. Then, we would have a system that worked. Mr. Olson. Can you identify any federal barriers as to why they are not collecting this data? Dr. Torrey. I would say they are not collecting the data because they have no interest in these questions. And one of the things you will learn early in government is you don't ask questions that you don't want the answers to. Mr. Olson. This question is one for you again, Dr. Torrey, and Dr. Satel, if you would please answer this question as well. How can SAMHSA maximize their resources for those with severe mental illnesses? Just blanket. I mean how can they do this because they are missing the target completely? How can they maximize the resources right here, right now, today? Dr. Torrey? Dr. Torrey. Well, there is a whole series of things they could do. First of all, you could look at the rate that Ms. Hyde talked about. Seventy percent goes to substance abuse, thirty percent to seriously mentally ill. I don't know why that ratio is as it is. It certainly should be at least 50/50 on it. Secondly, you can specify that SAMHSA must focus its resources on severe mental illness and report back on a regular basis. Third, I think a GAO investigation of the discretionary grants, things like the P and A program and other things is way overdue. I have looked at a few of these grants under Freedom of Information. They really look like they need some light of day looking at them, and I think that is one of the important things the Committee could do. Mr. Olson. Thank you, Dr. Torrey. Dr. Satel? Dr. Satel. Yes. I would like to mention, though, that when we are all saying severe mental illness as a large category, and, yes, it typically refers to bipolar, schizophrenia, the chronic psychoses, but what we are specifically talking about is the subset of the severely mentally ill who are so psychotic that they don't know they are ill and can't cooperate. So even if a program says it is dedicated for the severely mentally ill, that doesn't really answer the whole question. It has to also respond to those who are so sick and so debilitated that they cannot cooperate with that program. That is an important difference. But the more direct answer to your question, what I worry about in addition to what Dr. Torrey said is the active sabotage of the best interests of the mentally ill that SAMHSA underwrites. And again, the PAIMI, maybe if you kept the protection, I know they do some good things. I know there is certainly abuse in these institutions and someone needs to be a watchdog. The advocacy element has become very, very destructive. Also, even though there is not much money, as Administrator Hyde had mentioned that may go to Alternatives Conferences or consumer survivor groups, that money is leveraged so efficiently, these folks go out and they lobby state legislatures and they interfere with the passage of these AOT laws. I mean they are very efficient. So even if it is a small amount of money, it can have a much broader effect than many might expect. Mr. Olson. Thank you, ma'am. I am out of time. I will remember the term ``active sabotage.'' Thank you. Mr. Murphy. Thank you. I now recognize Mr. Griffith from Virginia for 5 minutes. Mr. Griffith. Thank you, Mr. Chairman. I appreciate all of you being here with your testimony and everything that you all have said. Great concerns about where we are spending our money and if we are spending it in the right places. I appreciate that, Dr. Torrey. I will tell you that the court system is very concerned about this. I spent 27 years before I came to Congress 2 \1/2\ years ago as a street lawyer as a lot of folks would say, dealt with families that were dealing with these issues, dealt with clients who were dealing with these issues. It is seen on a regular basis in every court across this country. And I will do a little shout-out for my hometown. They don't call it a mental health court because that isn't authorized at this point, but one of our judges has set up a therapeutic docket specifically because we had sufficient numbers even in our area of people who are in the criminal court system who need help. And it may not be that they are completely out of touch like that subset you are talking about, Dr. Satel, the severe mental illness, but they have got significant issues that the court needs to make sure somebody is dealing with it. If our mental health system isn't going to do it, the court system has got to try to figure out how to do it in a just manner. And so I commend Judge Talevi for setting that up. Mr. Bruce, in those regards, I would ask you what your son's condition was like before April 2006 and specifically if you could tell me, prior to killing his mother, had he had any contact with the criminal justice system? Mr. Bruce [continuing]. With the criminal justice system, but he had been brought to a hospital for evaluation in 2005 after pointing a loaded weapon at two people and coming within a hair of killing both of them. He was in a state of deep psychosis. At that time they decided not to send him to a commitment hearing after he had been on some Thorazine and a little bit of lithium and had calmed down because they said that he felt that he didn't meet the standard for involuntary commitment. Mr. Griffith. Who said that? Mr. Bruce. My wife and I waited in the psychiatrist's office for this commitment hearing to start. She got a call, said that was the hospital's lawyer and he felt that they didn't have a case so they weren't sending him to the commitment hearing. And I said what do you mean, no case? And she said, well, the standard is imminent danger, which actually is not the standard in Maine. It poses a likelihood of serious harm. But anyway, this is what happens when mental health people are forced to interpret law. I said, well, a couple weeks ago he almost killed two people. And she said, well, that was then and this is now. And I said, well, but you told me that in all likelihood the minute he leaves the hospital he is going to stop taking these medications which you yourself said are not even adequate for his disease. She said, how could I go before a judge and truthfully say that he was in imminent danger? Just look at him. I mean he was calm. He wasn't threatening anybody. Mr. Griffith. Well, what a tragedy and I am sorry for all the pain and the loss of your wife that you have had to go through over this. Mr. Bruce. Thank you. Mr. Griffith. Do you think at that time he was able to make decisions for himself that were rational? Mr. Bruce. No. No. Mr. Griffith. And you did obtain the guardianship in February 2007 and he was, I believe you said, found not guilty by reason of insanity, is that correct---- Mr. Bruce. Yes, sir. Mr. Griffith [continuing]. At the time of the offense? Mr. Bruce. Yes. Mr. Griffith. OK. Well, I hope that we can find some answers and I appreciate all of you all testifying today. I do think it is important that we have input at the court level because us street lawyers see a lot of mental illness in a lot of our clients and the family members know what is going on, so they need to be involved. And I have had many cases where the families kept folks from doing things that they might otherwise have done that could have caused problems. So I do appreciate it and appreciate all of your testimony today. Thank you. I yield back, Mr. Chairman. Mr. Murphy. Thank you. The gentleman's time is expired. I now recognize that Dr. Cassidy of Louisiana for 5 minutes. Mr. Cassidy. Dr. Parks, for the record, obviously one of my concerns--I am a doc, too, not a psychiatrist--but one of my concerns is that some of the SAMHSA money is going for folks who advocate doing without medications. And yet I have read from your testimony it seems as if you would reject that. You firmly seem to believe that medications have a role in the treatment of serious mental illness. Dr. Parks. Absolutely. That is correct, Representative. Mr. Cassidy. Yes. I am told that you are a primary investigator or a principal investigator on a number of SAMHSA- type studies? Dr. Parks. That is correct. Mr. Cassidy. May I ask what type of studies just quickly? Dr. Parks. The two that I am currently principal investigator on, one is suicide prevention on the mental health side. This has been a 10-year series of grants, many of them are direct congressional funding. They said spend this on suicide prevention, particularly with youth, the Garrett Smith Act. The second one is out of the CSA, the substance abuse side. And that is for a brief--that is for screening for excessive drinking and risky drug use with brief interventions following an assessment. It is a primary care intervention. Mr. Cassidy. I have just limited time so I get the---- Dr. Parks. Sorry. Mr. Cassidy. Do you feel as if your participation in those grants presents a conflict of interest in your testimony today? Just asking. Dr. Parks. I agree it could have the appearance of that. I am here as an expert. Mr. Cassidy. I accept that. I mean I can make do. Do you agree with Dr. Satel and Dr. Satel's statement that it is not the actual severe, severe mental illness; it is the people with severe mental illness which is beyond the current reach of society that seems to be ignored by the funding priorities of SAMHSA? Dr. Parks. No, I would not agree by that. That is who we are spending the block grant money on and that is certainly who we were treating with the COSIG grants that have now ended. These are the grants that serve people that have substance abuse problems and serious mental illness, greatly increasing their risk of violence. So I would not agree. Mr. Cassidy. Dr. Satel, how would you---- Dr. Satel. Yes, I would say that I have no question that Dr. Parks is treating people who have the diagnosis of schizophrenia and bipolar, and correctly so, but that they are not in that active phase where they are, again, so profoundly ill that they cannot even cooperate with your care. So--but that is the point I am making, again, distinguishing between--the question isn't does SAMHSA have programs that serve people with these illnesses; it is, do they serve them also in the most debilitated phase of that condition? Mr. Cassidy. So I gather it was your testimony or Dr. Torrey's regarding now the efforts seem to be those patients who actually can participate in their care but the issue is how do we reach those who cannot participate in their care? Dr. Satel. Yes, exactly. Mr. Cassidy. OK. I got that. And you stand by your statement--you heard me quote your testimony earlier speaking to Administrator Hyde that there is a--I forget your term, but there is a relative imbalance in terms of the compendium of care? Dr. Satel. Oh, I definitely stand by that. I did clarify it when you, I think, were out of the room that I mentioned that there were only four studies that explicitly mentioned severe mental illness in their description, but, as you also alluded to, that there were more programs that probably did--or definitely did attend to them. But again, we are back to that distinction between those who can cooperate and those who can't. Mr. Cassidy. So, Dr. Parks, I respect that you are frontline. I mean I have worked in a safety net hospital so I always figure frontline folks have a little bit of street cred. My impression, though, is that SAMHSA has somewhat lack of focus. You heard my questioning of the administrator. Would you disagree with that or do you feel like everything is working great, no problem, or would you accept what Dr. Torrey says, what in the heck are we spending $20,000 on an oil painting for? Dr. Parks. I have not yet found a governmental agency that couldn't improve its performance. Mr. Cassidy. Were you at Charity, by the way, Charity Hospital? Dr. Parks. I was at a daughter of Charity. Mr. Cassidy. OK. Dr. Parks. I am a Charity alum. Mr. Cassidy. Yes. Dr. Parks. That is where I did my internship---- Mr. Cassidy. Yes. Dr. Parks [continuing]. Wonderful experience. I think the major problem we have with SAMHSA is they are funding short. They cannot fund all their priorities adequately. In terms of the $20,000 painting, I can't support having funded that. That is $20,000 is very small dollars in the big picture of things. It is not an excuse to waste it but I think the proper policy focuses on the big picture dollars. Mr. Cassidy. And Dr. Torrey, I am sorry, I was out of the room with other responsibilities but is there anything that you would--you heard Administrator Hyde kind of contradict some of your assertions. Just now that I am back in the room, is there anything you would say to me as regards to her testimony? Dr. Torrey. Yes, can you repeat that, Dr. Cassidy? Mr. Cassidy. Yes, her response to my questions in which I suggested that there was a lack of focus, she seemed to feel as if there is not. I take it you stand by your assertions that that indeed there is a lack of focus and even a frivolity as to some of their spending? Dr. Torrey. Yes, it is not that there is no worthwhile programs. In SAMHSA there are some worthwhile programs but they are relatively few and far between. And I certainly stand by my statement that not only is severe mental illness not a priority; it is almost nonexistent. Mr. Cassidy. OK. I yield back. Thank you. Mr. Murphy. I thank the gentleman. And I want to thank all the panelists today and all the members, both sides of the aisle. It is clear we are all dedicated to coming up with some answers, a solution. Unfortunately, it was pointed out this may not have the publicity of the IRS hearings or Benghazi, but given that 20 percent of people have diagnosable mental illnesses in any given year and 38,000 people commit suicide I think last year, 750,000 suicide attempts, we all are very concerned. And I appreciate the dedication of all the members of this committee in trying to find some answers. I also want to restate my commitment and everyone's commitment to science-based evidence for real solutions. Good intentions do not guarantee good results, and as we move forward to come up with some solutions, I am pretty sure I speak for both sides of the aisle when I say that is what we are going to be looking for, good, effective results will do this. Again, I thank everybody and I want to then mention that in conclusion I remind members they have 10 business days to submit questions for the record. I ask the witnesses to please respond promptly to any of the questions. Again, Mr. Bruce, our prayers and our thoughts are with you and your family and I thank all the other panelists for this very important hearing today And with that, I adjourn. [Whereupon, at 1:10 p.m., the subcommittee was adjourned.] [Material submitted for inclusion in the record follows:] [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]